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3^ef  erence  l^itirarp 


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t 


PLATE  I 


Mottled  eruption 
from  the  arm  of 
same  case. 


Severe  Case  of  Scarlet  Fever,  showing  eruption  at  its  lieight.  For 
strawberry  tongue  ot  same  case,  see  Plate  XXVIll.  (Original.)  (Painted 
from  a  case  in  tlie  Riverside  Hospital.) 


DISEASES 


OF 


INFANCY  AND  CHILDHOOD 

THEIR 

Dietetic,  Hygienic,  and  Medical  Treatment 


A  TEXT-BOOK  DESIGNED  FOR  PRACTITIONERS 
AND  STUDENTS   IN  MEDICINE. 


BY 

LOUIS  FISCHER,  M.D. 

ATTENDING    PHYSICIAN    TO    THE    VTII^LARD    PARKER    A^•D    RIVERSIDE    HOSPITALS     OF    NEW    YORK 
CITY;    CHIEF    ATTENDING    PEDIATRIST    TO    THE    ZION    HOSPITAL    OF    BROOKLYN;    ATTEND- 
ING PEDIATUIST  TO  THE   SYDENHAM   HOSPITAL;   FORMER   INSTRUCTOR   IN   DISEASES 
OF    CHILDREN    AT    THE    NEW    YORK    POST-GRADCATE    MEDICAL    SCHOOL    AND 
HOSPITAL,    ETC.;    FELLOW   OF  THE   NEW    YORK  ACADEMY   OF   MEDICINE. 


SEVENTH      EDITION 


WITH  THREE  HUNDRED  AND  FIVE  ILLUSTRATIONS,  SEVERAL  IN 
COLORS,  AND  FORTY-THREE  FULL-PAGE  HALF- 
TONE AND  COLOR  PLATES 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  Publishers 

English  Depot: 

Stanley  Phillips,  London 

1917 


COPYRIGHT,  1907,  F.  A.  DAVIS  COMPANY 

COPYRIGHT,  190S,  F.  A.  DAVIS  COMPANY 

COPYRIGHT,  1910,  F.  A.  DAVIS  COMPANY 

COPYRIGHT,  1911,  F.  A.  DAVIS  COMPANY 

COPYRIGHT,  I9I4,  F.  A.  DAVIS  COMPANY 

COPYRIGHT,  1915,  F.  A.  DAVIS  COMPANY 
COPYRIGHT,  1917,,  F.  A.  DAVIS  COMPANY 

Copyright,  Great  Britain.    All  Rights  Reserved. 


V~  5  2_ 


Philadelphia,  Pa.,  U.  S.  A. 

Press  of    F.   A.   Davis   Company 

1914-16  Cherry  Street 


TO 

SIMON  FLEXNER,  M.D., 

DIRECTOR    OF    THE    ROCKEFELLER    INSTITUTE    FOR    SCIENTIFIC    RESEARCH, 
NEW  TORE, 

THIS  VOLUME  IS 
MOST  AFFECTIONATELY  INSCEIBED 

AS  A  SLIGHT  TRIBUTE  TO   AN   EARNEST   AND   DEVOTED  STUDENT, 

BY  THE  AUTHOR 


h- 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Conimons 


http://www.archive.org/details/diseasesofinfancOOfisc 


PREFACE  TO  SEVENTH  EDITION. 


Since  the  last  edition  appeared  research  in  pediatrics  has  enriched 
our  knowledge  regarding  the  cause  of  the  deficiency  diseases,  such  as  scurvy 
and  rickets.  It  has  been  experimentally  proven  that  these  diseases  are 
caused  by  a  lack  of  vitamines  in  the  food.  In  the  chapters  on  nutrition, 
therefore,  an  article  on  Vitamines  has  been  added. 

The  value  of  blood  transfusion  as  a  therapeutic  measure  is  described 
and  illustrated  by  clinical  cases. 

D^Espine's  sign  has  been  described.  Its  importance  as  an  aid  in  the 
detection  of  tuberculosis  in  its  earliest  stage,  before  the  lung-tissue  is 
destroyed,  has  been  established.  Tuberculides,  a  skin  manifestation  of 
tuberculosis  in  many  young  children,  has  been  illustrated;  so  also  the 
Schick  reaction,  which  is  of  great  value  in  showing  the  susceptibility  to 
dijihtheria,  especially  in  crowded  institutions. 

Vaccine  therapy  has  been  revised  with  especial  reference  to  dosage. 
Likewise  the  dosage  of  diphtheria  antitoxin  has  been  modified  according 
to  our  latest. views  at  the  City  Hospital  for  Diphtheria. 

The  recent  epidemic  of  poliomyelitis  (summer  of  1916)  in  New  York 
City  and  State  has  given  a  vast  opportunity  for  the  study  of  the  pre- 
paralytic stage,  and  to  judge  of  the  results  of  the  serum  treatment. 

Other  additions  to  the  present  volume  are:  The  complement  devia- 
tion test  in  suspicious  cases  of  pertussis.  The  use  of  adrenaline  in  serum 
rashes.  The  use  of  thromboplastine  in  the  chapter  on  hemorrhages.  The 
treatment  of  dropsy  and  suppression  of  urine  in  nephritis,  with  especial 
reference  to  the  diet  and  the  stimulation  of  the  kidneys,  and  a  new  article 
on  Erb's  Palsy. 

Minor  corrections  have  been  made.  Early  statistics  and  useless  cuts 
have  been  discarded  to  give  space  for  more  important  clinical  data. 

The  aim  of  the  book  has  been  to  present,  in  a  concise  manner,  prac- 
tical points  in  the  diagnosis  and  treatment  of  infantile  diseases,  for  the 
benefit  of  the  teacher  as  well  as  the  general  practitioner. 

Louis   Fischer. 


155  West  Eighty-fifth -Street, 
New  York  City. 


(^) 


CONTENTS. 


PAKT  I. 

DEVELOPMENT  AND  HYGIENE  OF  THE  INFANT. 
DIAGNOSTIC  SUGGESTIONS. 

CHAPTER  PAGE 

I. — Infancy   and   Ciiiluhood    1 

The  new-born  infant;  infancy,  childhood. 

II. — The  Development  of  the  Various  Senses   2 

Eeflex  actions;  sighing;  urine;  suckling  or  nursing;  supporting  the 
head;  sitting;  playing;  stamping  with]  the  feet;  the  first  attempts 
at  walking;  laughing;  kissing;  tears;  memory;  taste;  touch;  voice 
sounds;  very  late  speaking;  sudden  loss  of  speech  due  to  paralysis. 

III. — The  Development  of  the  Body   5 

Growth  and  height;  dentition. 

IV. — Diagnostic    Suggestions    9 

The  pulse-rate;  respirations;  temperature;  eye;  gestures;  cry; 
tongue;  throat;  sleep;  prognosis;  infant  mortality;  the  value  of 
X-ray  in  diagnosis. 

V. — General  Hygiene  of  the  Infant   17 

Hygiene  of  the  mouth  and  teeth;  management  of  the  navel;  the  um- 
bilical cord;  vernix  caseosa;  bathing  the  baby;  clothing;  the  nur- 
sery; ventilation;  when  to  take  an  infant  out-of-doors;  the  nurse- 
maid; method  of  heating  the  nursery;  light;  furniture;  bed  and 
pillow;  proper  training  of  bowels  and  bladder;  hygiene  of  the  nervous 
system;  physical  exercise. 


PART  11. 

ABNORMALITIES  AND  DISEASES  OF  THE  NEMT^Y  BORN. 

I. — Premature  Infants    26 

Management  of  a  premature  infant;  method  of  feeding;  premature 
birth;   artificial  feeding. 

II. — ^Prophylaxis  and  Treatment  of  the  Eyes  in  the  New-bobn 34 

III. — Diseases  and  Malformations  of  the  Umbilicus   35 

Granuloma;  diphtheritic  omphalitis;  dangers  incident  to  careless- 
ness in  handling  the  navel;  septic  omphalitis;  Meckel's  diverticulum; 
congenital  obliteration  of  the  bile  ducts. 

IV. — ^Hemorrhagic  Diseases  of  the  Newly  Born   39 

Spontaneous  htemorrhage;  umbilical  haemorrhage;  haemoglobinuria 
neonatorum;  acute  fatty  degeneration  of  the  new-born;  gastro- 
intestinal hfemoiThage. 

(vii) 


viii  CONTENTS. 

CHAPTER  PAGE 

V. — Injuries  of  the  New-boen   43 . 

Fractures;  obstetrical  paralysis. 

VI. — ^Asphyxia  Neonatokum    45 

VII. — FcETAL  Ichthyosis    50 

VIII. — Inflammatory  and  Non-infla5«:matoey  Conditions   52 

Icterus  neonatorum;  sclerema  neonatorum;  mastitis  neonatorum; 
erysipelas  in  the  new-born;  tuberculosis  in  the  new-born;  peritonitis 
in  the  new-born;  pemphigus  neonatorum. 

IX. — Abnokmauties  and  Congenital  Mali^oemations   57 

Angeioma;  harelip;  cleft  palate;  tongue-tie;  congenital  adenoids; 
protrusion  of  the  ears;  abnormalities  of  the  air  passage;  congenital 
stenosis  of  the  larynx;  prominent  sternum;  depressed  sternum; 
haematoma  of  the  sterno-mastoid ;  cephalhsematoma ;  caput  succeda- 
neum;  congenital  cyst  of  the  kidney;  congenital  sacral  tumor;  con- 
genital malformations  of  the  rectimi. 

PAKT  III. 

NUTRITION. 

1. — The  Infantile  Stomach  :     Beeast-milk  and  Wet-nuesing  65 

Colostrum;  breast-milk;  the  mammary  glands;  maternal  feeding; 
scanty  breast-milk  requiring  mixed  feeding;  disturbances  during  breast 
feeding;  immunity  conferred  by  breast-milk;  additional  foods  during 
the  nursing  period;  diet  of  a  nursing  mother;  wet-nurse;  weaning 
and  feeding  from  one  year  to  fifteen  months;  management  of  woman's 
nipples;  protein  indigestion;  weight  and  development. 

II.— Cows'   Milk    114 

Certified  milk;  adulteration;  raw  milk;  chemical  examination;  fat; 
sugar;  protein;  mineral  salts;   starch;   alkalies;   cream. 

III. — Home  Modifications  of  Milk   150 

Bottle-feeding  or  hand-feeding;  pasteurization;  diet  for  a  child  from 
one  year  to  fifteen  months;  diet  for  a  child  from  eighteen  months 
to  three  years;  diet  for  a  child  from  the  third  to  the  tenth  year;  feed- 
ing of  delicate  or  sick  children;  substitute  feeding;  feeding  bottles; 
nipples;  caloric  method  of  infant-feeding. 

.     IV. — Percentage   Feeding    170 

V. — Other  Substitute  Foods    173 

Goats'  milk;  buttermilk  feeding;  Bulgarian  milk;  Lahman's  vege- 
table milk;  Horlick's  food;  condensed  milk. 

VI. — Proprietary  Infant  Foods    181 

Nestle's  food;  Horlick's  malted  milk;  cereal  milk;  Wampole's  milk 
food;  Imperial  Granum;  Eskay's  albuminized  food;  Mellin's  food; 
Mammala;  Just's  food;  Benger's  food;  peptogenic  milk  powder. 

VII. — Concentrated  Preparations  of  Albumin   194 

VITI. — Additional  Nutrients  and  Stimulants   198 


CONTENTS.  ix 

PAET  IV. 

DISEASES    OF  THE   MOUTH,   CESOPHAGUS,    STOMACH,   INTESTINES, 

AND  RECTUM,  AND  DISORDERS  ASSOCIATED 

„,    ^^„  WITH  IMPROPER  NUTRITION.  „,^„ 

CHAPTER  PAGE 

I. — Diseases  of  the  Mouth   205 

Stomatitis;  stomatitis  catarrhalis;  stomatitis  aphthosa;  Bednar's 
aphthae;  parasitic  stomatitis;  croupous  stomatitis;  syphilitic  stoma- 
titis; stomatitis  gangrsenosa;  epithelial  desquamation;  congenital 
hypertrophy  of  the  tongue;  bifid  tongue;  bifid  uvula;  glossitis; 
ranula;   alveolar  abscess;  angina  Ludovici. 

II. — Diseases  of  the  CEsophagus  217 

Acute  oesophagitis;  croupous  or  diphtheritic  oesophagitis;  retro- 
oesophageal  abscess;  foreign  bodies  in  the  oesophagus. 

III. — Diseases  of  the  Stomach   219 

Acute  gastric  catarrh;  pyloric  obstruction  caused  by  spasm  of  the 
pylorus;  hypertrophic  pyloric  stenosis;  gastro-duodenitis;  chronic 
gastritis;  acute  dilatation  of  the  stomach;  gastroptosis;  ulcer  of 
the  stomach;  cyclic  vomiting;  dyspeptic  asthma. 

IV. — Diseases  of  the  Intestines   2.37 

Infant  stools;  bacteria  of  the  intestines;  diarrhoea;  insolation;  dys- 
entery; pellagra;  intoxication;  summer  diarrlioea;  constipation; 
Hirschsprung's  disease;  intestinal  colic;  chronic  intestinal  indiges- 
tion; appendicitis;  pseudo-appendicitis;  intussusception;  umbilical 
hernia;  worms;  uncinariasis. 

V. — Diseases  of  the  Rectum   294 

Fissure  of  the  anus;  simple  cataiThal  proctitis;  croupous  proctitis; 
ulcerative  proctitis;  hsemorrhoids ;  ischio-rectal  abscess;  pi'olapsus 
ani;  rectal  polypi. 

VI. — Deficiency  Diseases  and  Disorders  Arising  from  the  Improper  As- 
similation of  Nutrition  whereby  Faulty  ^Metabolism  Results.  298 
Faulty  metabolism;   scurvy;   rachitis;   decomposition. 

PAET  Y. 

DISEASES  OF  THE  HEART,  LWER,  SPLEEN,  PANCREAS, 
PERITONEUM,  AND  GENITOURINARY  TRACT. 

I. — Introductory    32.'5 

II. — Diseases  of  the  Heart   330 

Reflex  symptoms  of  the  heart,  tachycardia,  bradycardia;  pulmonary 
stenosis;  persistence  of  the  ductus  arteriosus  Botalli;  endocarditis; 
malignant  endocarditis;  pei'icarditis;  tuberculosis  of  the  pericar- 
dium; hydropericardium;  myocarditis. 

III. — Diseases  of  the  Liver   346 

Jaundice;  acute  congestion  of  the  liver;  gall-stones;  functional  dis- 
orders of  the  liver;  displacement  of  the  liver;  descended  liver;  amyloid 
degeneration;  fatty  liver;  cirrhosis;  focal  necrosis;  subphrenic 
abscess. 


X  CONTENTS. 

CHAPTER  PAGE 

IV. — "Diseases  of  the  Spleen  and  Pancbeas  352 

v.— Diseases  of  the  Peritoneum   354 

Acute  peritonitis;  clironic  peritonitis;  tuberculous  peritonitis: 
ascites. 

VI. — Diseases  of  the  Genital  Organs   Stil 

Hernia;  hydrocele;  adherent  prepuce;  phimosis;  paraphimosis;  hypo- 
spadias; epispadias;  cryptorchidism;  orchitis;  vulvo-vaginitis ; 
simple  vaginitis;  gpnorrhceal  vaginitis;  vicarious  menstruation; 
menstruation  prsecox. 

VII. — Diseases  of  the  Kidney  and  Bladder  370 

Acute  nephritis;  secondary  nephritis;  perinephritis;  pyelitis;  ectopia 
vesicae  congenitalis;  indicanuria ;  acetonuria;  diacetonuria ;  pyuria; 
lordotic  albuminuria;  hsematuria;  heemoglobinuria ;  glycosuria; 
diabetes  insipidus ;  diabetes  mellitus ;  colicystitis ;  vesical  calculi ; 
acute  cystitis;  chronic  cystitis;  enuresis. 

PAKT  VI. 

.  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

I. — Diseases  of  the  Nose  and  Tkeoat 391 

Acute  nasal  catarrh;  naso-pharyngeal  catarrh;  influenza;  foreign 
bodies  in  the  nose;  tonsillitis;  follicular  tonsillitis;  croupous  ton- 
sillitis; ulcero-membranous  tonsillitis;  phlegmonous  tonsillitis;  chronic 
hypertrophic  tonsillitis;  tuberculosis  of  the  tonsils;  adenoid  vegeta- 
tion; pharyngitis;  retropharyngeal  abscess;  spasmodic  laryngitis; 
foreign  bodies  in  the  larynx;  coughs  of  reflex  origin. 

II. — Diseases  of  the  Bronchi,  Lungs,  and  Pleura  423 

Bronchitis;  bronchial  asthma;  broncho-pneumonia;  pleurisy;  dry 
pleurisy;  pleurisy  with  effusion;  empyema;  chronic  empyema;  tuber- 
cular empyema. 

PAET  YII. 

THE  INFECTIOUS  DISEASES. 

I. — Fever.     Bacterial  Vaccines   ' 445 

II. — Pertussis   (Whooping-cough ) 455 

III. — Pneumonia    460 

IV. — Tuberculous  Broncho-pneumonia :     Pulmonary  Gangrene   479 

V. — Acute   Tuberculosis    483 

VI. — Diphtheroid.       Pseudo-diphtheria.       Acute     Diphtheria.       Chronic 

Diphtheria.     Intubation.    Tracheotomy 500 

VII. — ^Rubella  (German  Measles).    Duke's  Disease  (Fourth  Disease)    ...  577 

VIII. — Measles    (Morbilli,  Rubeola)    584 

IX. — Scarlet  Fever   ( Scarlatina) 599 

X. — ^Varicella  (  Chicken  Pox  ) 633 


CONTENTS.  xi 

CIIAPTEU  PACK 

XI. — Variola  and  Vaccination   638 

XII. — Typhoid  Fever   646 

XIII. — Erysipelas    658 

XIV.— JIal^vria    662 

XV. — Syphilis    672 


PAET  VIII. 

DISEASES  OF  THE  BLOOD,  GLAl^DS  OR  LYMPH-NODES, 
AND  DUCTLESS  GLANDS. 

I. — Introductory    G8.3 

II. — DiSKiVSES   OF   THE   BlOOD    691 

Anaemia;  splenic  antemia;  secondary  anfemia;  pernicious  anaemia; 
leukaemia;   pseudo-leukcemic  anaemia;   chlorosis. 

III. — Acute  Rheumatism    698 

Muscular  rheumatism;  torticollis;  pui-pura;  purpura  rheumatica; 
Henoch's  purpura;   lithaemia;   haemophilia. 

IV. — Diseases  of  the  Glands  or  Lymph  Nodes  711 

Status  lymphaticus ;  acute  adenitis;  chronic  adenitis;  tubercular 
adenitis;  mumps. 

V. — Diseases  of  thei  Ductless  Glands   719 

Cretinism;  exophthalmic  goiter;  acute  thyroiditis;  abnormality  of  the 
thyroid;  diseases  of  the  thymus  gland;  diseases  of  the  adrenal  glands; 
Addison's  disease.  -  .      . 


PAET  IX. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

I. — Fontanel   733 

Percussion  of  the  skull;  the  brain;  reflexes. 

II. — Convulsions    739 

Headaches;  spasmus  nutans;  speech  defects;  chorea;  hysteiia; 
multiple  neuritis;   pavor  nocturnus;   masturbation. 

III. — Tetany    756 

Spasmophilia;  tetanus;  epilepsy;  myelitis;  spina  bifida;  hereditary 
ataxy;  poliomyelitis;  hydrocephalus;  meningocele;  encephalocele ; 
Cyclops ;   porenceplialy. 

IV. — Tubercular  Meningitis    779 

Cerebro-spinal  meningitis;  pachymeningitis;  cerebral  paralysis;  pleu- 
roplegia;  pseudohypertrophic  paralysis;  facial  paralysis;  cerebral 
abscess;  alalia  idiopathica;  idiocy  and  imbecility;  infantile  amaurotic 
family  idiocA';   concussion  of  the  brain. 


Xii  CONTENTS.     • 

PAET  X. 

DISEASES   OF  THE  EAR,  EYE,   SKIN,  AND 
ABNORMAL  GROAVTHS. 

CHAPTER  PAGE 

I. — Diseases  of  the  Ear    812 

Acute  catarrhal  otitis  media;  mastoid  operation;  sinus  thrombosis; 
foreign  bodies  in  the  ear. 

II. — Diseases  oe  the  Eye    , 819 

Acute  catarrhal  conjunctivitis;  pink  eye;  pneumococcus  ophthalmia; 
purulent  ophthalmia;  membranous  conjunctivitis;  granular  ophthal- 
mia; blepharitis;   hordeolum;   phlyctenular  conjimctivitis. 

III. — Diseases  of  the  Skin  827 

Eczema;  eczema  rubrum;  eczema  intertrigo;  urticaria;  herpes  zoster; 
chloasma;  psoriasis;  impetigo;  pediculosis;  miliaria  papulosa; 
miliaria  rubra;  sudamina;  lentigo;  seborrhoea;  furuncle;  chronic 
pemphigus;  erythema;  nsevus;  tinea  tonsurans;  verruca;  burns; 
gangrene;   scabies. 

IV. — ^Malignant  and  Non-maugnant  Growths   842 

Spindle-cell  sarcoma;  carcinoma;  hypernephroma;  lipoma;  enchon- 
dromata;  angeioma;  malignant  and  non-malignant  papillomata; 
granulomata. 

PAET  XI. 

DISEASES  OF  THE  SPINE  AND  JOINTS. 

Diseases  of  the  Spine  and  Joints  848 

Pott's  disease;  flat  foot;  scoliosis;  morbus  coxarius;  congenital  dislo- 
cation of  the  hip;  knee-joint  disease;  diseases  of  the  ankle-joint  and 
tarsus;  wrist-joint  and  elbow-joint  disease;   acute  arthritis. 
Hypodermic  medication. 


PAET  XII. 

MISCELLANEOUS. 

I. — Dietary 868 

II. — The  Examination  of  the  Gastric  Contents  ; 875 

III. — Urine    " 877 

IV. — Bacteriological  Memoranda   888 

v.— Anaesthetics   in    Children    890 

VI. — Disinfection    894 

VII. — The  Administration  of  Drugs   895 

VIIL— Local  Remedies   896 

IX. — Rectal  Medication   898 

X. — Prescriptions  for  Various  Diseases    900 

XL — Table  of  Doses   909 


LIST  OF  ILLUSTRATIONS. 


FIGURE  PAGE 

1.  A,  Tympanic  cavity.    B,  Otic  ganglion.     C,  Tooth.     D,  Internal  carotid.     E, 

Tympanic  branch.  F\  Auriculo-temporal  nerve.  G,  Auricular  branch 
of  auriculo-temporal  nerve.  The  dotted  line  connecting  B  and  C  repre- 
sents  the   inferior  dental   nerve ' 6 

2.  Two   middle  lower   incisors.     Nine   to   sixteen   months 8 

3.  Four  upper  incisors.     Nine  to  sixteen  months 8 

4.  Two  lateral  lower  incisors  and  four  molars.     Thirteen  to  seventeen  months.  8 

5.  Four   canines.     Sixteen   to    twenty-one    months 8 

6.  Twenty   milk   teeth.     Twenty-three   to   thirty-six   months 8 

7.  Proper-shaped    shoe    for    infant , 21 

8.  Incubator   27 

0.  Feeder   for   premature    infants 31 

10.  Funnel  and  catheter  for  forced  feeding.  .'. 31 

11.  Weight  chart    32 

12.  Case  of  omphalocele    36 

13.  Appearance  of  abdomen  four  weeks  after  treatment 36 

14.  Diagram  illustrating  effects  of  persistence  of  the  omphalomesenteric  dvict, 

and  the  formation  of  the  so-called  diverticulum  tiuuor 37 

15.  Eibemont's  tube  for  inflating  the  lungs 47 

16.  Infant  pxilmotor    48 

17.  A  case  of  angeioma    57 

18.  Harelip  nipple    58 

19.  Congenital  cystic  kidney 62 

20.  Congenital  sacral  tumor 63 

21.  Infant's  stomach.     Actual  size.     From  a  case  of  malnutrition 69 

22.  Infant's  stomach.    Actual  size.     Died  suddenly  from  convulsions 69 

23.  Infant's  stomach.     Capacity,  10  ounces.     Age  of  child,  eleven  months., 70 

24.  Infant's  stomach.     Capacity  of  measurement,  14  ounces 70 

25.  Colostrum  corpuscles  in  a  drop  of  milk 75 

26.  Heeren's  pioscop,  for  optical  milk  test 79 

27.  Specimen  of  breast-milk  from  a  young  mother,  17  years  old 81 

28.  Specimen  of  breast-milk,  illustrating  very  high  fat,  causing  gastric  disturb- 

ance      81 

29.  Showing  a  drop  of  milk  under  the  microscope 90 

30.  Drop  of  breast-milk  from  a  very  anaemic  woman   90 

31.  Holt's  milk  test  set,  for  testing  human  milk 91 

32.  Nipple-shield  for  relief  of  tender  nipples 93 

33, 34.  Breast-pump    93,   94 

35.  Breast-milk  taken  from  a  wet-nurse  during  menstruation 102 

36.  Pear-shaped  breasts,  best  adapted  for  nursing 106 

37.  The  Chatillon  scale    108 

38.  Chart  showing  gain  in  weight  of  baby  Robert  M.  F 110 

39.  Chart  showing  gain  in  weight  of  baby  J.  S Ill 

40.  Chart  showing  gain  in  weight  of  baby  fed  on  Eskay's  food  after  third  week.  Ill 

(xiii) 


xiv  LIST    OF    ILLUSTRATIONS. 

FIGURE  PAGE 

41.  Chart  shoAving  gain  in  weight  of  baby  A 112 

42.  Chart  showing  gain  in  weight  of  baby  D.  S 112 

43.  Centrifugal  testing  machine,  for  handpower    133 

44.  Graduated  cream  gauge   134 

45.  Marchand's  tube 134 

46.  Feser's  lactoseope    134 

47.  Cows'  milk,  showing  fat-globules    135 

48.  Chapin  cream  dipper   ■ 147 

49.  Author's  choice  of  feeding-bottle  151 

50.  Bottle  warmer    151 

51.  Bottle-brush    152 

52.  Anticolic  nipple   152 

53.  Nipple-sterilizer   153 

54.  Enterprise  juice  extractor   200 

55.  Case  of  sprue  (thrush)   due  to'  faulty  hygiene  of  the  mouth   207 

56.  Case  of  stomatitis  gangrenosa  (noma)   following  scarlet  fever 212 

57.  Hinged  bucket   218 

58.  Infantile  duodenal  bucket  Avith  syringe  attached,  to  aspirate  bile 225 

59.  Drawing  from  a  case  of  acute  dilatation  of  the  stomach   230 

60.  Translumination  of  the  stomach  with  the  aid  of  a  gastrodiaphane,  in  a  case 

of  gastroptosis.      ( Colored. )    232 

61.  a,  Normal  position  of  stomach.     6,  Position  of  stomach  in  a  case  of  gas- 

troptosis  ••  •  233 

62.  Bacterium  coli  commune   243 

63.  Bacterium  lactis  aerogenes   244 

64.  Chart  of  death-rate  from  diarrhoea  in  Manhattan  and  Bronx,  1898,  1899.  .  .  247 

65.  Chart  of  death-rate  from  diarrhoea  in  Manhattan  and  Bronx,  1900,  1901 .  .  .  248 

66.  Chart  of  death-rate  from  diarrhea  in  Manhattan  and  Bronx,  1902,  1903 249 

67.  Insolation   (heat  stroke) 250 

68.  Bacillary  diphtheria  of  the  colon  or  diphtheritic  colitis.      (Colored.)    252 

69.  Croupous  enteritis,  diphtheritic  colitis 253 

70.  A  case  of  acute  milk  poisoning 257 

71.  Exact  size  of  catheter  used  for  irrigating  a  very  young  infant  . 262 

72  to  77.  Abnormalities  of  the  sigmoid  flexure   267 

78.  Rubber  bulb  syringe 209 

79.  Irrigator,  Avith  tube  attached  and  hard-rubber  points  270 

80.  Soft- rubber  rectal  tube  for  Irrigating  the  colon   271 

81.  Mechanism  of  intussusception 286 

82.  Umbilical  hernia 288 

83.  Umbilical   hernia  truss    289 

84.  Case  of  hydrencephaloid    (spurious  hydrocephalus)    308 

85.  Same  child,   two  years  later    308 

86.  Rickets,  longitudinal  section  tlirough  ossification  junction  of  upper  diaphy- 

seal end  of  femur 309 

87.  A  case  of  spurious  hydrocephalus,  illustrating  marked  frontal  and  parietal 

protuberances    310 

88.  Rachitic  ribs 312 

89  to  92.  Illustrating  rachitic  ciosions  of  tlie  pcnnaniMit  teeth    313 

93.  Five-week-old  fracture  of  the  humerus  in  a  rachitic  child  l^^  years  old  ....  314 

94.  A  severe  type  of  rickets,  Avith  enlargement  of  both  condyles  of  the  femur.  .  ;  314 

95.  Case  of  rickets,  showing  enlarged  spleen;  also  pendulous  belly 315 


LIST    OF    ILLUSTRATIONS. 


XV 


FIGURE  PAGE 

96.  Rickets,  showing  beaded  ribs  and  an  onlaif^cd,  pciiiliiloiis  belly   317 

97.  Rickets,   showing  beaded   ribs    .318 

98.  Rachitic  kyphosis   (spine) .     Front  view 310 

99.  Racliitic  kyphosis    (spine).     Back  view,  same  child   319 

100.  Decomposition   322 

101.  Infantile  atrophy 323 

102.  Apex  beat  in  a  very  young  infant 326 

103.  Apex  beat  in  a  child  about  6  years  old 326 

104.  Apex  beat  in  child  about  12  years  old   326 

105.  Irregular  pulse,  low  tension,  from  a  case  of  mitral  regurgitation 327 

106.  Natural  size  of  Rowles  stethoscope  for  examining  children   328 

107.  Convenient  stethoscope  for  children    328 

108.  Case  of  pulmonary  stenosis — congenital — blue  baby  333 

109.  Child  with  persistence  of  the  ductus  arteriosus  Botalli  33.5 

110.  Case  of  tubercular  peritonitis  complicated  by  tul)frcular  empyema   357 

111.  Gonoeoecus.     (Colored.)    307 

112.  Nephritis  complicating  diphtheria    372 

113.  Case  of  pyelonephritis   377 

114.  Exstrophy  of  the  bladder,  and  prolapse  of  anus   379 

115.  Atomizer 392 

116.  Lefferts's  posterior  and  anterior  nasal  syringe  393 

117.  Lenox  nasal  douche 394 

118.  Graduated  douche,  suitable  for  older  children   394 

119.  Influenza  bacilli.      ( Colored. )    : 396 

120.  Case  of  influenza  pneumonia  in  a  child  eight  months  old   397 

121.  Case  of  influenza  pneumonia  in  a  child  two  years  old  399 

122.  Angina  tonsillaris   (Colored. ) 403 

123.  Vincent's  bacillus  found  in  ulcerative  angina   406 

124.  Throat  spray    407 

125.  Throat  ice-bag . 407 

126.  The  Baginslcy  tonsillotome   ■ 409 

127.  The  Mackensie  tonsillotome 409 

128.  Typical  adenoid  face  in  a  cretin  412 

129.  Digital  method  of  exploring  the  rhino-pharynx  for  adenoids 413 

130.  Temperature  chart  from  a  case  of  retropharyngeal  abscess   417 

131.  Oil  atomizer 418 

132.  Steam  atomizer   419 

133.  Croup  kettle 421 

134.  Diplococeus  pneumoniae    ( pneumococcus ) .      (Colored.)    430 

135.  Purulent    ( svippurative )   bronchitis,  peribronchitis,  and  peribronchial  l)nin- 

cho-pneumonia  in  a  cluld  fifteen  months  old   431 

136.  Diphtheria   (septic)   bronch'o-pneumonia.     Louis  B.,  age  three  years   432 

137.  Diagram  for  pneumonia  jacket  opened  at  side    434 

138.  Diagram  for  pneiunonia  .jacket  opened  at  front   434 

139.  Fever  curve  in  a  case  of  dry  pleurisy 436 

140.  Fever  curve  in  a  case  of  pleurisy,  with  effusion   438 

141.  Diagrammatic  illustration  of  heart  ajul  lungs,  left-sided  pleuritic  efl'usion .  .   439 

142.  Illustrating  a  severe  localized  riglit-sided  empyema    441 

143.  James's  apparatus  for  expanding  the  lungs  in  empyema  443 

144.  Temperature  chart,  Case  II,  broncho-pneumonia 453 


xvi  LIST    OF    ILLUSTRATIONS. 

FIGURE  PAGE 

145.  Focal  metastatic  hsematogenous  streptococcus — pneumonia  following  angina. 

(Colored.)     461 

146.  Croupous  pneumonia.      (Colored.) 461 

147.  Case  of  influenza  and  pneumonia  463 

148.  Lobar  pneumonia  of  a  severe  type 467 

149.  Case  of  cerebral  pneumonia   468 

150.  Cerebral  pneumonia,  with  high  temperature  and  marked  decrease  in  tem- 

perature after  cold  baths   469 

151.  Fever  curve  during  the  early  period  of  clironic  pulmonary  tuberculosis  ....  479 

152.  Temperature  curve  during  the  fifth  month .'....  479 

153.  Chronic  nodular  tuberculous  broncho-pneumonia  480 

154.  Tubercle  bacilli  and  micrococcus  tetragenus   (sputum).      (Colored.)    487 

155.  Tuberculosis — horizontal  section  through  lower  lobe  of  right  lung  of  two- 

year-old  child 489 

156.  Acute  pulmonary  miliary  tuberculosis  (cut  surface  of  the  lung)    490 

157.  Diphtheria  or  Klebs-Loeffler  bacilli ;    smear  preparation  from  tonsillar  de- 

posit.     ( Colored. )     505 

158.  True  and  false  diphtheria    ■ .  506 

159.  Section  from  an  inflamed  imila  covered  with  a  stratifled  fibrinous  mem- 

brane, from  a  case  of  diphtheritic  croup  of  the  pharyngeal  organs  ....  509 

160.  Septic  type  of  diphtheria,  comjDlicated  by  myocarditis  513 

161.  Case  of  nasal  diphtheria 514 

162.  Broncho-pneumonia  complicating  diphtheria 515 

163.  Pneumonia   complicating   diphtheria    521 

164.  Temperature  chart  from,  a  case  of  diphtheria  complicated  by  broncho-pneu- 

monia  (step-ladder  type  of  fever)    524 

165.  Temperature  chart  from  a  case  of  diphtheria  complicated  by  lobar  pneu- 

monia     525 

166.  Temperature  chart  from   a  case   of   diphtheria  complicated  by   otitis  and 

meningitis    526 

167.  Temperature  chart  from  a  case  of  diphtheria,  showing  the  specific  eff"ect  of 

antitoxin  on  the  temperature   535 

168.  Method  of  transfixing  and  raising  the  vein 536 

169.  Introducer  Avith  tube  attached  545 

170.  Introducer  with  tube  and  detached  obturator 545 

171.  Introducer  holding  foreign-body  tube   545 

172.  Extubator    546 

173.  Built-up  tubes  for  granulation  tissue   546 

174.  The  mummy  bandage,  showing  child  in  proper  position  for  the  dorsal  method 

of  intubation 547 

175  Intubation.     Left  index  finger  raising  the  epiglottis  548 

176.  Tube,  passing  the  epiglottis,  entering  the  larynx 549 

177.  Tube,  resting  on  vocal  cords,  in  the  larynx   550 

178.  Extubation.     The  left  index  finger  finding  the  tube 551 

179.  Cliart  showing  laryngeal  diphtheria  complicated  by  broncho-pneumonia   .  .  .  552 

180.  Gavage — method  used  in  forced  feeding  «,t  Willard  Parker  Hospital 555 

181.  Casselberry  method  of  feeding  556 

182.  Temperature  chart  from  a  case  of  diphtheria:    croup,  intubation 557 

183.  Laryngeal  diphtheria 564 

184.  Diphtheria — ^^laryngeal  stenosis  requiring  intubation   571 

J85,  Temperature  chart  from  a  case  of  laryngeal  diphtheria 572 


LIST    OF    ILLUSTRATIONS.  XvU 

FIGUBE  p^Qj, 

186.  Silver  trachea  cannula  used   in  traciieotxjmy    575 

187.  Hard-rubber  tracliea  cannula  575 

188.  Temperature  chart,  ease  of  rubella   580 

189.  A  case  of  malignant  measles  complicated   by   diphtheria  and  ending  with 

empyema 59 1 

190.  191.  Temperature   charts,   cases   of   measles/  complicated   by    broncho-pneu- 

"lonia 592^  593 

192.  "Inclusion  bodies,"  case  of  scarlet  fever   qqi 

193.  Septic  scarlet  fever  with  myocarditis,  suppurative  arthritis,  double  purulent 

otitis,  general  pyaemia  005 

194.  Unusually  severe  desquamation   G07 

195.  Chart  showing  temperature  and  complications  in  a  case  of  scarlet  fever   .  .  609 

196.  Septic  nephritis   (515 

197.  Drop  of  urine  from  a  case  of  post-scarlatinal  nephritis 616 

198.  Coffey's  glass  apparatus  for  hypodermic  saline  injections   621 

199.  Temperature  chart,  scarlet  fever  treated  with  antistreptococcus  serum   ....  625 

200.  Method  of  nasal  siyringing  employed  in  the  scarlet  fever  ward  of  the  River- 

side Hospital   626 

201.  Pustules  surrounded  by  inflammatory  areola   633 

202.  Temperature  curve  in  varicella 635 

203.  Erysipelas  following  varicella   636 

204.  Fatal  smallpox  in  an  unvaccinated  infant   638 

205.  Temperature  curve  in  variola _ 640 

206.  Smallpox  in  a  child  that  was  vaccinated  during  the  incubation  period   ....  641 

207.  Mild,  discrete  smallpox  in  an  unvaccinated  girl  643 

208.  Typlioid  infantum  in  a  two-year-old  boy  647 

209.  Stages  in  Widal  reaction  650 

210.  Typhoid  fever.     Severe  hsemorrhages 652 

211.  Ectogenous  streptococcus  infection.      (Colored.)     658 

212.  Fever  curve  in  facial  eiysipelas  • 659 

213.  Malaria  plasmodia,  tertian  type.      (Colored.) 663 

214.  Malaria  plasmodia,  tropical  form.     (Colored.)    663 

215.  Tertian  fever    (intermittent)    664 

216.  Quartan  fever    (double  tertian)     665 

217.  ^stivo-autumnal  fever   (mild  type)    666 

218.  Spirochseta  pallida.    Macerated  skin  of  f(»tus 674 

219.  Syphilis.     Child  14  years  old   677 

220  to  223.  Syphilitic  teeth 679 

224.  Congenital  syphilis  before  injection  of  salvarsan 680 

225.  Appearance  of  lesions  one  week  after  injection  of  salvarsan   681 

226.  Blood  from  a  case  of  chlorosis   697 

227.  Malignant  purpura,  complicating  nasal  diphtheria 706 

228  Case  of  cervical  adenitis  in  which  a  positive  von  Pirquet  reaction  appeared.   715 

229  to  234.  Sporadic  cretinism 721,  723 

235  to  242.  A  case  of  cretinism 725,  726,  727,  728 

243.  Sagittal  section  of  normal  head  of  seven  and  one-half  months'  foetus 734 

244.  Normar  head  as   seen  from  above 734 

245.  Sagittal  section  of  normal  head   734 

246.  Sagittal  section  of  head  inmiedjately  after  normal,  easy  labor   734 

247.  248.  Sagittal  section  of  head  immediately  after  labor    735 

249.  Sagittal  section  of  head  of  infant  six  days  old  735 


xviii  LIST    OF    ILLtJSTRATIOKS. 


250.  Tetany    756 

251.  Case  of  spina  bifida  766 

252.  Micro-organism  causing  epidemic  poliomyelitis   708 

253.  Poliomyelitis 769 

254.  Infantile  paralysis    771 

255.  Infantile  paralysis    771 

256.  Infantile  paralysis 773 

257.  258.  Case  of  chronic  internal  liydrocephalusi   775 

259.  Hydroeeplialic    calvarium     (or    sknll-cap),    widely    gaping    fontanels    and 

sutures    777 

260.  Case  of  eneephalocele    778 

261.  Tuberculous  spinal  meningitis 780 

262.  Case  of  tuberculous  meningitis,  well  marked,  ending  fatally 782 

263.  Anatomical  illustration,  showing  the  place  best  adapted  for  lumbar  pimc: 

ture   789 

264.  Lumbar  puncture  needle   789 

265.  Lumbar  puncture  made  between  fourth  and  fifth  lumbar  vertebrae 790 

266.  Infantile  cerebral  paralysis 797 

267.  Pseudohypertrophic  paralysis   801 

268.  Facial  paralysis  following  mastoid  operation 802 

269  to  271.  A  case  of  pseudohypertrophic  paralysis   803 

272.  Congenital  idiocy 807 

273  to  276.     Imbecile  (Louie  W.) 808,  809 

277.  Complication  of  scarlet  fever  seen  in  my  sexvice  at  Riverside  Hospital  ....  813 

278.  Ear  syringe 814 

279.  A  common  type  of  acute  mastoid  inflammation  following  influenza 817 

280.  Trachoma,  showing  round,  opaque  bodies  in  upper  and  lower  lids   824 

281.  Method  of  everting  eyelid  825 

282.  Case  of  gangrene  following  lobar  pneumonia   840 

283.  Spindle-cell  sarcoma • 843 

284.  Anterior  view  of  the  tumor 844 

285.  Enchondromata  involving  the  thumb  and  index  finger  846 

286.  Pott's  disease   ". 848 

287.  Pott's  disease,  case  of  Harry  F , 853 

.288,  289.  Schoolgirl,  showing  lateral  curvature  of  spine,  due  to  faulty  position .  .  855 

290.  Side  flexion 859 

291.  Position  maintained  while  ten  or  twenty  deep  breaths  are  drawn .  859 

292.  Sitting-hanging  with  rod  860 

293.  Resistance,  especially  adapted  for  young  children   860 

294.  295.  Tuberculous  coxitis    862 

296.  Congenital  hip  dislocation  863 

297.  Tubercular  elbow- joint  866 

298.  Urino-pyloiometer,  for  estimating  the  specific  gravity  of  small  volumes  of 

urine   880 

299.  The  horismascope  or  albumoscopQ 882 

300.  Gas  and  ether  inhaler   890 


LIST  OF  PLATES. 


PLATE  PAGE 

I. — Severe  case  of  scarlet  fever,  showing  eruption  at  its  height.  .Frontispiece 

II.— Hess  Incubator 28 

III. — The  Byrd-Dew  method  of  artificial  respiration   46 

IV. — A  drop  of  normal  breast-milk  from  primipara   SO 

V. — Microscopic  appearance  of  raw  sitarch-granules   144 

VI. — Microscopic  apiiearance  of  starch-granules,  showing  the  cfl'cc-t  of  heat  144 

VII. — Geographical  tongue,  or  epithelial  desquamation    214 

VIII. — Intussusception.      (Courtesy  of  Dr.  Hen)    286 

IX. — Intussusception.      (Coiirtesy  of  Dr.  Reu)    286 

X. — Cestodes    (tape- worms)     288 

XI. — Infantile  scurvy   .302 

XII. — Femur  divided  by  anteroposterior  section  in  case  of  infantile  scurvy.  .302 

XIII. — Subperiosteal  haemorrhages  in  case  of  infantile  scuryj^ 304 

XIV. — Flaring,  cup-shaped,   irregular  termination  of  diaphyses  in  rickets. 

Condition  accounts  for  enlargement  of  wrists  in  rickets   308 

XV. — Flaring,  cup-shaped,   irregular  termination  of  diaphyses  in  rickets. 

Condition  accounts  for  enlargement  of  ankles  in  rickets 308 

XVI. — Chronic  enlarged  tonsils.     Granular  pharyngitis   412 

XVII.- — Disseminated  pulmonary  tuberculosis,  with  collapsed  right  lung  and 

natural  pneumothorax    490 

XVIII. — Papulonecrotic  tuberculides    496 

XIX. — Cutaneous  reaction  with  concentrated  and  diluted  tubercailin 498 

XX. — Severe  cutaneous  reaction.     Scrofulous  reaction  498 

XXI. — A,  Common  type  of  diphtheria.    B,  Follicular  type  of  diphtheria.    C, 

Hsemorrhagic  type  of  diphtheria.    D,  Septic  type  of  diphtheria.  514 

XXII. — Morbilliform  antitoxin  rash   516 

XXIII.— Schick  reaction  520 

XXIV.— Schick  reaction 520 

XXV.— Intubation 548 

XXVI.— Extubation    '. 550 

XXVII. — Earliest  symptoms  of  measles 584 

XXVIII. — Forms  of  tongue  in  scarlet  fever   604 

XXIX. — Furfuraceous,  circinate,  and  flaky  desquamations 606 

XXX. — Confluent  type  of  smallpox   644 

XXXI. — lodophilia.     Pus  reaction  of  blood  686 

XXXII. — A,  Progressive  pernicious  an?emia.    B,  Lienal   (splenic)   an«mia.     C, 

Lienal    (splenic)    leukemia.     7>,  Acute  leukivniia   692 

XXXIII. — Henoch's  purpura    'i^^ 

XXXIV.— Front  view  of  the  foetal  skull  736 

XXXV.— Top  view  of  the  foetal  skull  736 

XXXVL— Posterior  view  of  the  foetal  skull 736 

XXXVIL— Disseminated   pulmonary  tuberculosis   in   two-year-old  child  having 

tubercular  meningitis    i^*^ 

(xix) 


XX  LIST  OF  PLATES. 

PLATE  PAGE 

XXXVIII. — 1,  Meningococci  in  pus  cells  784 

XXXIX. — Cerebrospinal   meningitis 786 

XL. — Cerebrospinal  meningitis  due  to  the  influenza  bacillus ■ 788 

XLI. — Intracranial  injection  in  meningitis 792 

XLII.— Normal  mucous  membrane  of  the  middle  ear  in  the  new-born.  In- 
flammation of  the  mucous  naembrane  of  the-  middle  ear.  Sec- 
tion of  the  vessel  of  the  mucous  membrane  containing  strepto- 
coccus   pyogenes    812 

XLIII. — ^X-ray  of  congenital  dislocation  of  hip 858 


PART  I. 

THE  DEVELOPMENT  AND  HYGIENE  OF  THE  INFANT. 
DIAGNOSTIC  SUGGESTIONS. 


CHAPTER  I. 
INFANCY  AND  CHILDHOOD. 

The  New-born  Infant. 

There  are  several  anatomical  and  physiological  changes  which  occur 
when  an  infant  passes  from  a  passive  intrauterine  to  an  active  extrauterine 
existence.  The  lungs  have  had  no  intrauterine  function.  They  become 
active  as  soon  as  the  infant  makes  its  first  inspiration.  The  stomach  and 
bowels  become  active  the  moment  the  first  mouthful  of  food  is  swallowed. 
The  blood-vessels  of  the  umbilical  cord,  which  have  nourished  the  child 
and  connected  it  with  the  circulatory  system  of  its  mother,  rapidly  atrophy 
as  soon  as  breathing  is  established.  The  following  are  the  most  important 
changes  that  take  place  during  the  first  month  of  an  infant's  life : — 

1.  The  meconium  is  expelled. 

2.  The  umbilical  cord  separates. 

3.  The  navel  becomes  cicatrized. 

4.  The  epidermis  cracks  and  falls  off. 

5.  The  hair  is  renewed. 

6.  The  uml)ilical  vessels  are  obliterated,  and  the  foramen  ovale  is  closed. 
Infancy. — The  term  infancy  is  best  applied  to  that  period  from  the 

end  of  the  first  month  until  all  of  the  milk-teeth  have  appeared,  which  is 
about  the  end  of  the  second  year  of  life. 

There  are  certain  anatomical  peculiarities  Avhieh  may  l)e  important  to 
mention,  namely : — 

1.  The  thymus  gland. 

2.  The  large  size  of  the  liver. 

3.  The  existence  of  an  anterior  and  posterior  fontanel. 

Childhood. — The  term  childhood  is  applied  to  that  period  from  tlie 
end  of  the  second  year  to  about  the  sixteenth  year. 

Childhood  ends  when  puberty  begins.  Then  follows  tlie  stage  of  adoles- 
cence. 

(1) 


CHAPTER  II. 

THE  DEVELOPMENT  OF  THE  VARIOUS  SENSES. 

Mental  Faculties.^ 

The  following  is  the  order  in  which  the  various  senses  appear  devel- 
oped:  taste,  sight,  touch. 

Heflex  Actions. — Yawning  may  begin  at  the  end  of  the  first  week  of 
life. 
(^    Sighing^  commences  in  the  twenty-eighth  week. 

Urine  is  passed  and  attention  called  to  it  by  the  infant  between  the 
thirty-sixth  and  fortieth  weeks.  From  this  time  on  it  is  advisable  to  try  to 
train  the  child  to  be  clean  and  use  a  chair. 

Suckling  or  Nursing. — This  seems  to  be  congenitally  acquired.  Be- 
tween the  eighth  and  tenth  months  an  infant  should  know,  enough  to  prop- 
erly guide  a  nursing  bottle  to  its  mouth.  It  should  also  know  enough  to 
properly  inspect  its  various  toys  at  this  age. 

Supporting  the  Head. — The  infant  should  support  its  head  for  a  few 
moments  in  the  fourteenth  week,  and  should  be  able  to  properly  support 
the  head  about  the  sixteenth  week. 

Sitting  usually  commences  between  the  seventeenth  and  twenty-sixth 
weeks.  The  child  should  be  able  to  properly  support  the  body  between  the 
thirty-sixth  and  fortieth  weeks.  About  the  forty-second  week  the  child 
should  be  strong  enough  to  support  its  back  thoroughly.  Commencing  with 
the  forty-fifth  week  the  sitting  position  should  be  permanently  established. 

When  children  can  sit  up  and  play  they  should  be  placed  on  the  floor, 
having  a  clean  rug  under  them.  Active  movements  can  be  suggested  by 
rolling  a  small  ball  or  giving  the  child  some  toy  to  play  with.  The  tendency 
to  put  everything  into  the  mouth  must  be  considered.  Hence,  large  toys, 
such  as  hollow  rubber  balls,  are  best.  Playing  with  beans,  peas,  and  bullets 
has  frequently  given  many  a  physician  an  opportunity  to  try  his  skill  in 
removing  them  from  such  places  as  the  middle  ear,  the  nostril,  and  most 
frequently  the  stomach.- 

Stamping  with  the  feet  in  the  forty- fourth  week. 

The  first  attempts  at  walking  appear  about  the  forty-first  week.  WaU-- 
ing  unaided  is  rare  Ijefore  the  end  of  the  first  year.    Two-fifths  of  all  children 

^  The  brain,  fontanel,  and  reflexes  of  the  body  ai'e  described  in  detail  in  Part 
IX,  "Diseases  of  the  Brain  and  Nervous  System." 

(3) 


VERY  LATE  SPEAKING.  ^  3 

Icain  to  walk  between  tne  I'ourteeiitli  and  lil'teeiitli  inoiitlis.  'J'lius  eliildron 
must  ]J<)t  be  exjtected  to  walk  properly  until  ihe}'  are  one  and  a  lialf  years 
old. 

Children  having  sufl'ered  with  disordered  stoniach  and  bowels,  whether 
from  faulty  fee(lin<r  or  inherited  disease  (syphilis)  or  other  organic  dis- 
orders, ma}',  ii'  urged  to  walk  in  this  weakened  condition,  invite  deformities, 
such  as  bow-legs. 

Children  will  not  jump,  climb,  iJirow  tltlngs,  or  turn  unaided  before 
they  are  between  two  and  three  years  old. 

Infants  do  not  learn  to  imUale  before  the  twenty-eighth  week. 

Laughing  begins  as  early  as  the  eighth,  sometimes  not  before  the 
seventeenth,  week.  An  infant  will  laugh  heartily  with  tears  in  its  eyes 
about  the  forty-fourth  week.  The  mouth  will  show  an  expression  the  mo- 
ment the  infant's  attention  is  attracted,  between  the  third  and  seventh  week. 

Kissing  with  the  lips  usually  at  the  fifteenth  month. 

Tears,  when  crying,  can  be  noticed  after  the  tenth  week. 

Memory. — The  memory  of  an  infant  can  be  noticed  sometimes  before 
the  thirtieth  week. 

The  taste  of  milk,  the  sense  of  feeling,  the  sight  of  the  mother,  the 
presence  of  the  father  or  the  nurse,  are  distinctly  apparent  about  this  same 
time.  An  infant  will  notice  the  absence  of  its  mother  about  the  fourth 
month,  and  also  notice  the  difference  in  the  sound  of  the  voice.  The  memory 
seems  to  be  most  acute  in  the  fourth  year  of  life.  It  is  surprising  to  see 
how  much  children  wall  remember,  and  how  acute  their  mental  faculties 
will  be,  in  the  fourth  year  of  life. 

Voice  Sounds. — Children  will  study  the  movements  of  the  mouth  of 
adults,  and  will  learn  to  note  the  difference  in  sound.  They  will  remember 
the  meaning  of  words,  especially  when  brought  into  use  in  connection  with 
certain  objects  or  places.  Words  will  be  uttered  in  accordance  with  no  dis- 
tinct rule.  This  is  a  peculiar  individuality  which  is  ditficult  to  record. 
One  child  will  speak  ten  words  at  the  age  of  ten  months,  and  be  in  a 
normal  condition.  Another  child  will  speak  but  six  words  at  the  age  of 
sixteen  months  and  yet  be  physically  and  mentally  in  a  normal  condition. 
This  shows  the  marked  difference  in  various  children  in  apparently  good 
health. 

Very  Kvte  Speaking,   Slow   DEVELOPirEXT.   Good   Progxosis.^ 

The  center  of  speech  may  be  inactive,  and  show  no  signs  of  develop- 
ment until  the  end  of  the  second  year.  If  the  child  is  otherwise  healthy 
no  alarm  need  be  felt  at  this  state  of  affairs.  If,  however,  the  child  is 
backward  in  its  physical  development  as  well  as  its  mental  development. 


'Sec  article  on  "Alalia  Tdiopathica,"  Part  IX. 


4  DEVELOPMENT  OF  THE  VARIOUS  SENSES. 

then  treatment  must  be  sought  to  remedy  this  condition.     If  a  child  has 
rickets,  its  soft  bones  and  flabby  muscles  require  restorative  treatment. 

Sudden  Loss  of  Speech  Due  to  Paralysis. 

If  an,  infant  shows  proper  development,  commences  to  speak,  and  for 
no  apparent  reason  stops  speaking,  the  cause  of  the  condition  should  be 
carefully  mvestigated.  For  example:  A  child  suffering  from  a  severe 
infectious  disease,  like  diphtheria,  may,  dunng  convalescence,  develop 
paralysis,  which  might  cause  the  sudden  cessation  of  speech.  The  neglect 
of  treatment  at  such  a  time  may  result  in  permanent  injury  to  the  child. 


CHAPTER  III. 

THE  DEVELOPMENT  OF  THE  BODY. 

GnowTir  AM)   iri;r(;ii'r. 

The  average  height  of  the  new-l)()ni  nuile  is  from  19V2  to  20  inches 
(ahout  50  centimeters).  In  the  female  from  V.)%  to  19%  inches  (about 
48.5  centimeters).  Jlolt's  average  is  one  inch  more  in  both  male  and 
female  ehihlren  at  birtli.     A  cliild  grows  most  rapidly  during  its  first  year. 

Taule  No.  1. 
Incveaso   during 

First  year   5  to  6  Vj  inches. 

Second    year    2  '/a  to  '.V/._,  inches. 

Third    year    . 2 '/s  to  2  7=  inches. 

Fourth   year    about  2  inches. 

Fifth  to   sixteenth  year    annual  increase  from  1'/::  to  2  inches. 

Sixteentlx  to  seventeenth  year   .  1  V2  inches. 
Seventeenth  to  twentieth  year  .  1  incli  yearly. 

Diseases  of  the  bones,  rickets,  and  scrofula  retard  growth.  A  child 
should  begin  to  walk  at  the  end  of  twelve  months.  If  a  child,  wdien  com- 
mencing to  walk,  uses  chiefly  its  toes  and  has  a  limping  gait,  more  espe- 
cially if  symptoms  of  pain  be  noticed  in  one  knee,  and  tenderness  be  caused 
by  handling  the  limb,  commencing  hip-joint  disease  may  be  inferred. 

Dentition". 

Dentition  is  regarded  by  most  authors  as  a  physiological  ])rocess.  Teeth 
are  developed  at  birth  and  grow  with  the  infant  until  they  pierce  the  gum, 
A  series  of  nervous  disorders  occur  after  the  fourth  month  and  during  the 
eruption  of  the  teeth.  Such  symptoms  are  a  very  warm  mouth,  red  and 
inflamed  gums,  and  an  excessive  secretion  of  saliva.  Eachitic  children  and 
those  having  a  liighly  sensitive  nervous  system  will  be  very  restless  at  night. 
They  will  roll  the  head  arid  frequently  cry  with  pain,  A  finger  will  usually 
be  found  between  the  gums,  and  the  child  will  try  to  l)ite  everything  Avithin 
its  grasp.  These  symptoms  seem  to  disappear  after  the  eruption  of  the 
tooth,  so  there  seems  to  be  some  relation  between  the  tooth  and  the  symptoms 
described.  Eotch  states  that  in  certain  infants,  during  the  completion  of 
the  development  of  a  tooth,  symptoms  connected  with  the  ear  will  manifest 
themselves.  The  symptoms  are  usually  produced  by  a  congestion  of  the 
blood-vessels  of  the  ear  which  is  accompanied  by  pain  and  sometimes  results 
in  an  inflammation. 

(5) 


6 


THE  DEVELOPMENT  OF  THE  BODY. 


Treatment  of  Inflamed  Gums. — When  the  gums  are  tense  and  inflamed, 
severe  nervous  manifestations  frequently  exist.  An  incision  made  into  the 
gums,  deep  enough  to  reach  tlie  tooth,  has  frequently  been  the  means  of 
joroducing  relief  by  local  depletion.  Kelieving  the  tense  gum  besides 
abstracting  the  blood  has  served  me  in' some  cases.  The  indiscriminate 
lancing  of  the  gums  must  be  warned  against.  In  most  cases  local  applica- 
tion will  relieve.  The  application  of  a  1  to  5000  solution  of  adrenalin  acts 
very  well.  It  may  be  repeated  every  hour.  A  drop  of  laudanum  on  absorb- 
ent cotton  placed  in  the  middle  ear  seems  to  act  well  in  some  instances. 
In  rare  instances  we  will  be  told  that  a  child  has  had  convulsions.  I  must 
emphatically  reiterate  that  such  cerebral  or  nervous  symptoms  are  apt  to 
occur  in  the  sick  infant,  and  will  never  occur  in  the  healthy  infant. 


Fig.  1. — A,  tympanic  cavity;  B,  otic  ganglion;  C,  tooth;  D,  internal 
carotid;  E,  tympanic  branch;  F,  auriculo-temporal  nerve;  G,  auricular 
branch  of  auriculo-temporal  nerve.  The  dotted  line  connecting  B  and  C 
represents  the  inferior  dental  nerve.      (Rotch. ) 


The  association  of  bronchitis  or  diarrhoea  must  be  looked  upon  as 
entirely  independent  of  dentition.  The  laity  are  very  willing  to  ascribe 
most  disorders  arising  at  or  about  the  period  of  dentition  as  due  to  the 
teething.  The  following  case  will  illustrate  how  careful  one  must  be  not 
to  be  guided  by  the  statements  of  irresponsible  persons,  and  diagnose  den- 
tition : — 

A  child,  fifteen  months  old,  was  seen  by  me  in  consultation.  This  was  a  well- 
nourished,  breast-fed  infant,  and  had  four  incisors,  two  upper  and  two  lower.  The 
mother  stated  that  the  child  had  had  a  cough  and  fever  at  and  before  the  appearance 
of  each  tooth.  She  was  very  emphatic  in  stating  that  her  baby  was  "teething." 
There  were  anore.xia  and  slight  constipation.  A  dose  of  castor-oil  was  given,  but  the 
symptoms  continued.  The  child  was  very  thirsty  and  seemed  to  lose  flesh.  The 
temperature  in  the  rectum  was  103°  F.,  pulse  150,  respiration  30.  An  examination 
of  the  chest  showed  moist  rales  and  quite  diffuse  rhonchi.  There  were  a  marked  area 
of  dullness  and  bronchial  breathing  in  the  upper  lobe  of  the  right  side.  The  diag- 
nosis of  pneumonia  was  made.     Four  or  five  weeks  later  I  again  saw  this  child.     The 


DENTITION.  7 

coiigli  atill  oxiatod,  and  a  suspicion  of  wliooping-pougli  was  pxprcssed.  An  explora- 
tory |)vni(tiirp  sliowcd  pus.  Tho  diagnosis  of  oiupyenia  was  made.  The  child  was 
operated  uiuni  and  made  a  brilliant  recovery. 

The  teeth  usually  appear,  according  to  Professor  Bagiiisky,  between 
tlie  third  and  tenth  months.  The  usual  rule  is  for  normal  dentition  to  hegin 
about  the  seventh  or  the  eighth  montli. 

In  a  great  variety  of  children  ])reniature  teething  is  recorded;  I  have 
seen  a  great  many  children  born  with  two  or  more  teeth. 

Eachitic  children,  as  a  rule,  teeth  very  early  or  very  late.  In  the  large 
children's  service  with  which  I  have  been  connected  I  have  observed  the 
eruption  of  teeth  many  times  as  early  as  two  or  three  months  in  very  rickety, 
bottle-fed  children.  These  teeth  soon  decay,  and  are  then  known  as  carious 
teeth. 

In  syphilitic  (congenital)  children  premature  dentition  is  frequently 
seen. 

The  first  teeth  are  known  as  milk-teeth. 

The  following  table  will  show  the  usual  rule  followed  by  normal  denti- 
tion in  the  average  child : — 

Table  No.  2. 

19  I  11  I  13  I  5  I  3  I  4  I  6  I  14  I  9  j  17 

20  I  12  I  1.5  I  7  I  1  I  2  I  8  I  16  I  10  I  18  - 

The  milk-teeth  are  twenty  in  number ;  thus,  one  and  two  are  the  lower 
incisors,  usually  first  teeth ;  then  follow  three  and  four,  upper  incisors. 

Normal  children,  usually  teeth  in  pairs,  and  not  singly,  whereas  rachitic 
children  usually  have  an  eruption  of  single  teeth,  and  distinct  backward- 
ness in  their  appearance.  Deciduous  teeth,  commonly  called  milk-teeth, 
remain  until  a  child  is  6  years  old,  when  the  permanent  teeth  appear. 

Baginsky  emphasizes  the  fact  that  enough  stress  is  not  laid  on  the 
clinical  importance  of  carious  teeth  as  indicating  tuberculosis  and  scrofulous 
conditions.  In  the  section  on  treatment  of  rickets  I  have  mentioned  the 
value- of  a  nitrogenous  diet,  especially  proteins  (albuminoids),  to  aid  in 
the  formation  of  bony  structures.  The  teeth  are  also  included  in  this 
category. 

Thus,  when  such  drugs  as  glycerophosphate  of  lime  or  iron  and  hygienic 
measures  are  indicated  for  the  treatment  of  rickets  they  are  of  especial 
value  when  backwardness  in  teething  exists. 

When  diarrhoea  or  cholera  infantum  cleanses  the  system  and  when  the 
disease  is  arrested  or  w^ell  under  way,  normal  physiological  conditions,  such 
as  dentition  previously  delayed,  are  vigorously  continued.  Frequently  teeth 
will  appear  immediately  following  such  an  acute  disease;  thus,  an  apparent 
delayed  dentition,  due  to  a  pathological  process,  will  be  attributed  by  the 
laity  to  the  disease  or  sickness  called  teething. 


THE  DEVELOPMENT  OF  THE  BODY. 


Fig.  2. — Two  Middle  Lower  In- 
cisors. Three  to  Ten  Months; 
Average,  Seven  Months. 


Fig.  3. — Four  Upper  Incisors, 
to  Sixteen  Months. 


Nine 


Fig.  4. — Two  Lateral  Lower  Incisors  and  Four  Anterior  Molars. 
Thirteen  to  Seventeen  Months. 


Fig.  5. — Four  Canines.     Sixteen  to 
Twenty-one  Months. 


Fig.  6. — Twenty  Milk  Teeth.  Twenty- 
three  to  Thirty-six  Months,  although  the 
Average  is  Twenty-four  to  Tliirty  Months. 


CllAl'TEK  IV. 
DIAGNOSTIC  SUGGESTIONS.^ 

It  is  a  very  difficult  matter  to  give  as  distinct  clinical  pictures  of 
children  in  certain  diseases  as  we  can  of  adults.  The  followinfr  points  are 
important  enough  to  be  noted : — 

First. — There  is  an  absence  of  expectoration  in  respiratory  diseases. 
Infants  cough  and  usuall5^  swa'low  their  expectoration. 

Second. — An  absence  of  distinct  chills  and  rigors  as  seen  in  adults. 

Third. — The  tongue,  so  valuable  in  adults  as  an  aid  to  diagnosis,  may 
frequently  be  overlooked  as  a  symptom  of  importance  in  young  children. 

Fourth. — Very  high  temperature  and  pulse-rate  may  be  associated  with 
trivial,  just  as  well  as  they  only  too  frequently  denote  serious,  conditions. 
A  normal  temperature  is  frequently  seen  in  septic  diphtheria ;  we  must, 
therefore,  not  judge  a  case  by  the  temperature  alone. 

•  Fifth. — The  great  peristaltic  activity  and  the  anatomical  difference 
in  the  shape  of  the  stomach  at  birth  render  such  Bym])toms  as  vomiting  and 
diarrhoea  trivial  compared  with  what  such  symptoms  would  denote  in  an 
older  and  fnlly  developed  child. 

Dr.  "West  ably  says :  "You  cannot  question  your  patient,  or,  if  old 
enough  to  speak,  still,  through  fear,  or  from  comprehending  you  But  im- 
perfectly, he  will  probably  give  you  an  incorrect  reply.  You  try  to  gather 
information  from  the  expression  of  his  countenance,  but  the  child  is  fretful 
and  will  not  bear  to  be  looked  at;  you  endeavor  to  feel  his  pulse,  and  he 
struggles  in  alarm;  you  try  to  auscultate  his  chest,  and  he  breaks  into  a 
violent  fit  of  crying."  Such  technical  difficulties  each  medical  man  must  try 
to  overcome,  and  here  it  is  that  the  ingenuity  of  the  practicing  physician  is 
brought  into  play. 

There  are  a  great  many  important  points  which  have  a  bearing  upon 
the  diagnosis  and  which  it  is  well  to  formulate:  First,  try  to  examine  the 
infant  when  asleep.  Note  the  color  of  the  face,  if  flushed  or  pale;  the 
color  of  the  lips,  if  white  or  cyanotic;  the  condition  of  the  skin,  if  dry  or 
moist;  if  perspiration  is  confined  to  the  head  or  forehead,  or  if  it  affects 
the  whole  body.  Second,  note  the  frequency  and  character  of  respiration, 
if  painful  or  natural ;  moaning,  twitching,  or  grinding  of  teeth ;  the  action 


'  The  Babinski  reflex,  Keinig's  sign,  tache  cerebrale,  and  the  technique  of  lumbar 
puncture  are  described  in  detail  in  the  chapter  on  "'Menin^tis,"  Part  IX. 

(9) 


10  DIAGNOSTHZ!  SUGGESTIONS. 

of  the  nostrils,  if  quiet  or  dilating;  the  eyes  if  closed,  partly  closed,  or 
staring.  Third,  note  the  conditioii  of  the  fontanels,  if  closed  or  open,  if 
pulsating,  if  distended,  full,  and  bulging,  or  if  sunken. 

The  pulse-rate  should  be  noted.  In  counting  the  pulse-rate  certain 
allowances  must  be  made  for  excitement.  The  sudden  slamming  of  a  door, 
etc.,  Avill  startle  infants  and  cause  the  pulse  to  increase  at  times  from  ten 
to  twenty  beats. 

The  pulse  varies  in  infants  from  110  to  150.  It  may  be  irregular,  con- 
sistently with  health.  After  the  seventh  year  it  is  found  to  be  quicker  in 
the  female.  It  is  sometimes  sloAver  during  sleep.  A  very  slow  pulse  is  not 
always  an  indication  of  cerebral  disease. 

In  a  study  of  over  1000  children  in  health,  the  following  average  table 
of  pulse  was  found  (Fischer)  : — 

Table.  No.  3. 

At  birth 130  to  140 

First  year  • 115  to  130 

Second  year  100  to  1 15 

Third  year  90  to  100 

Seventh  year 86  to  96 

Fourteenth  year  84  to  94 

Table  No.  4. 

Pulse  Rate: 

While  Asleep.  Awake,  Crying. 

Infant  ten  days  old 146  164 

One  month  old    150  176 

Two  months  old   120  150 

Three   months  old    112  148 

Six  months  old   . 98  122 

One  year  old   100  120 

Two  years  old 98  108 

A  diagnosis  can  frequently  be  made  by  the  condition  of  the  pulse-rate 
added  to  the  general  condition.  If  an  infant  is  suddenly  taken  ill  with 
fever,  with  symptoms  of  nausea  and  vomiting,  a  dry  coated  tongue,  and  the 
pulse-rate  about  130,  we  may  look  for  an  acute  gastric  fever.  Such  is 
usually  the  case  if  the  history  points  to  a  diet  of  cake  and  pie,  or  cheese,  in 
a  very  young  child. 

If,  however,  the  child  is  feverish  and  vomits  and  the  pulse-rate  is 
between  70  and  80,  then  we  should  suspect  tubercular  meningitis  rather 
than  an  acute  febrile  disease.  Note  the  condition  of  the  child's  awakening; 
every  young  infant  in  a  healthy  condition  awakens  with  a  smile,  does  not 
frown,  is  not  peevish. 

Frequently,  if  the  clinical  history  is  looked  into,  we  can  learn  just 
when  the  infant  first  became  restless  or  showed  some  sign  of  disturbance. 


TEMl'KRATl  UK.  11 

This  Avill  usually  mark  the  beginning  of  an  illness,  if  the  same  is  an  acute 
condition. 

The  Respirations. — From  1  to  2  years  of  age  a  cliiM  sliould  breathe 
from  24  to  3G  times  in  a  minute.  'JMie  breathing  should  be  diaphragmatic 
in  character;  in  ordinary  breathing  tiicre  should  be  no  recession  of  the 
chest  walls;  this  occurs  in  sobbing  or  if  a  mechanical  impediment  exists 
to  the  entrance  of  air  into  the  lungs. 

The  number  of  respirations  per  minute  ranges  from  30  to  50;  in 
early  infancy  39  is  the  actual  average. 

Table  No,  5. 

From  two  months  to  two  years,  the  average  is  35. 
From  two  years  to  six  years,  the  average  is  18  during  sleep,  2.3  awake. 
From  six  years  to  twelve  years,  the  average  is  18  during  sleep,  23  awake. 
From  twelve  years  to  fifteen  years,  the  average  is  18  during  sleep,  20  awake. 

Temperature. — The  normal  temperature  of  the  child,  taken  in  the 
rectum,  varies  between  99%°  and  100°  F.  Fever  undoubtedly  exists  if. tem- 
perature over  100°  F.  is  noted.  The  cause  should  be  searched  for.  No 
indication  is  more  simple  or  more  valuable  than  that  supplied  by  the  ther- 
mometer. By  its  aid  alone  we  are  often  led  to  suspect  the  advent  of  typhoid 
or  scarlet  fever,  or  to  detect  some  latent  pneumonia,  or  tubercle  produc- 
ing irritation,  or  some  other  malady  which  we  had  overlooked.  It  should 
be  remembered  that  rigors  do  not  occur  in  very  young  children,  but  that 
convulsions  and  delirium  correspond  in  a  great  measure  to  rigors  and 
headache  in  an  adult.  The  temperature  is  an  important  guide  as  to  the 
condition  of  an  infant.  The  pulse-rate  and  the  character  of  the  pulse  are 
even  more  important. 

Dr.  Finlayson  has  bestowed  much  attention  on  the  subject  of  tempera- 
ture in  young  children,  and  his  observations  go  to  show : — 

1.  That  there  is  a  fall  of  temperature  normally  in  the  evening  of  1°, 
2°,  or  even  3°  F. 

2.  This  fall  may  take  place  before  sleep  begins. 

3.  It  is  usually  greatest  between  7  and  9  p.m. 

4.  The  minimum  is  at  or  before  2  a.m. 

5.  After  2  a.m.  it  again  rises,  and  that  independently  of  food,  etc., 
being  taken — rises,  in  fact,  during  sleep. 

G.  The  fluctuations  between  breakfast  and  tea  are  usually  trifling. 

7.  The  rise  in  a  day  to  104°  or  105°  F.  precludes  typhus  and  typhoid, 
not  scarlatina. 

8.  In  typhoid  a  gradual  increase  for  the  first  four  days  with  morning 
remissions  is  diagnostic  (Wunderlich). 

9.  In  tubercle  the  evening  temperature  is  as  high  or,  according  to  Dr. 
Ringer,  higher  than  in  the  morning. 


12  DIAGNOSTIC  SUGGESTIONS. 

Rules  to  be  Observed  in  Taking  Temperature  of  Ineants. 

1.  Be  sure  you  have  a  good  thermometer. 

2.  Inspect  it  and  see  that  it  is  well  shaken  down  to  below  normal  before 
using  it. 

3.  Anoint  it  with  vaseline  or  oil. 

4.  Always  use  the  rectum  for  infants. 

5.  Remember  that  infants  always  object  to  interference;  hence  the 
thermometer  should  be  watched;  otherwise  an  accident  may  happen. 

6.  The  best  position  for  the  child  is  to  lay  it  face  downward  on  the 
nurse's  lap. 

7.  Remember  that  impacted  faeces  in  the  rectum  and  fermentative  con- 
ditions usually  increase  the  temperature. 

The  Eye. — Squinting  in  acute  illness  is  a  grave  prognostic;  it  may 
occur  from  reflex  irritation,  or  from  paralysis,  or  from  convulsions,  but  the 
convulsions  may  cease  and  the  squint  remain  for  awhile)  or  even  perma- 
nently. When  strabismus  occurs  in  tubercular  meningitis,  it  is  usually  a 
fatal  sign. 

A  small  pupil  is  not  so  common  as  a  large  one;  it  occursi  in  active 
congestion,  in  opium  poisoning,  and  in  sleep.  It  should  be  remembered 
that  the  eye  is  always  more  or  less  turned  up  beneath  the  upper  lid.  Large 
pupils,  if  equal  in  size,  are  only  of  grave  import  when  insensible  to  light; 
inequality  of  the  pupils  coming  on  in  acute  illness  is  a  very  grave  prog- 
nostic. M.  Jadelot  has  noticed  that  the  form  of  the  pupil  is  irregular  iii 
children  suffering  from  the  intestinal  irritation  of  worms. 

The  following  aphorisms  of  Bouchut  are  of  practical  value : — 

1.  In  early  childhood  there  is  no  relation  between  the  intensity  of  the 
symptoms  and  the  material  lesion.  The  most  intense  fever,  with  restless- 
ness, cries,  and  spasmodic  movements,  may  disappear  in  twenty-four  hours 
without  leaving  any  trace. 

2.  Abundant  perspiration  is  not  observed  in  very  young  children;  it 
is  entirely  replaced  by  moisture. 

3.  Fever  always  presents  considerable  remissions  in  the  acute  diseases 
of  young  children. 

4.  In  the  chronic  diseases  of  infancy,  fever  is  almost  always  inter- 
mittent. 

5.  When  children  are  asleep  their  pulse  diminishes  from  15  to  20 
beats.  The  muscular  movements  which  accompany  cough,  cryiiig,  agitation, 
etc.,  raise  the  pulse  15,  30,  or  even  40  pulsations. 

6.  The  diseases  of  youth  always  retard  the  process  of  growth. 

It  is  a  good  plan  to  auscultate  the  chest  before  resorting  to  percussion. 
The  back  of  the  chest  is  the  most  important  to  auscultate  in  a  sick  child. 
If  there  are  no  physical  signs  pointing  to  bronchitis  or  pneumonia  in  the 


THE    CRY.  13 

back  of  the  lungs,  then  it  is  unlikely  that  the  front  of  the  chest  will  show- 
any  signs.  To  be  sure,  liowever,  both  back  and  front  of  chest  should  be 
examined. 

Dr.  Vogel  gives  a  valuable  caution,  viz.,  that  dullness  on  the  right  side 
posteriorly  is  a  normal  physiological  condition.  Owing  to  abdominal 
pressure  the  abdominal  organs,  and  notably  the  liver  (as  especially  affecting 
the  right  side),  is  pressed  upward. 

Gestures  are  often  significant.  In  brain  disease  the  child  puts  its 
hand  to  its  head,  pulls  at  its  hair,  rolls  its  head  on  the  pillow,  and  beats  the 
air.  In  abdominal  disease  the  legs  are  drawn  up,  the  face  is  sunken  and 
anxious,  and  the  child  picks  at  the  clothes.  In  urgent  dyspnoea  it  tears 
at  its  throat  or  puts  its  hand  in  its  mouth,  especially  when  false  membranes 
are  forming,  or  the  tongue  is  much  furred,  as  in  fever,  etc. 

The  cry  varies;  it  is  labored,  as  if  half  suffocated,  or  as  if  a  door  were 
shut  between  the  child  and  the  hearer,  in  pneumonia  and  capillary  bron- 
chitis ;  it  is  hoarse  in  croup,  brassy  and  metallic,  with  crowing  inspirations ; 
in  cerebral  disease,  especially  in  hydrocephalus,  it  is  sharp,  shrill,  and  soli- 
tary, the  so-called  ''^cri  hydrocephalique,"  whereas  in  marasmus  and  tuber- 
cular peritonitis  it  is  moaning  and  wailing.  Obstinate  and  long-continued 
crying  lasting  for  hours  is  referable  usually  to  one  of  two  causes;  earache 
or  hunger.  A  louder,  shriller  cry,  also  on  coughing  or  produced  in  moving 
the  child,  is  pleuritic.  A  cry  accompanied  with  wriggling  and  writhing  and 
preceding  defecation  is  intestinal.  M.  Billard  distinguishes  between  the 
cry  and  the  return,  the  cry  proper  being  the  expiratory  act,  while  the 
return  occurs  during  inspiration.  The  cry  proper  is  sonorous  and  prolonged ; 
the  return  is  short.er  and  sharper;  the  return  is  feeble  in  young  infants, 
but  increases  in  strength  as  the  child  grows  older.  It  is  the  return  that 
grows  weak  or  ceases  toward  the  end  of  all  diseases.  Moaning  is  especially 
characteristic  of  the  alimentary  canal. 

The  Tongue.  — The  following  are  the  chief  indications  derived  from 
observations  of  the  tongue:  1.  A  furred  tongue  with  whitish  fur  scattered 
over  it  indicates  dyspepsia  and  intestinal  irritation.  2.  A  red,  dry,  hot 
tongue  points  to  inflammation  of  the  mouth,  stomach,  etc.  3.  Aphthae  often 
result  from  sheer  starvation  and  neglect.  4.  A  pale  flabby  tongue  marked 
at  the  edges  with  the  teeth  shows  great  debility.  5.  White  fur  is  generally 
indicative  of  fever.  6.  Yellow  fur  of  liver  and  stomach  derangement  of 
long  standing.  7.  Brown  fur  of  a  low  typhoid  condition.  Besides  these, 
special  conditions,  as  the  "strawberry  tongue"  of  scarlatina,  the  glazed 
tongue  of  dyspepsia,  etc.,  will  be  noted  under  the  special  diseases  they  char- 
acterize. 

The  Throat. — No  matter  ivhat  the  child  suffers  with,  it  is  imperative 
to  examine  the  throat.  Advantage  can  be  taken  of  the  infant  while  crying 
to  observe  the  tongue,  the  teeth,  the  gums,  the  mouth  in  general,  and  the 


14  DIAGNOSTIC  SUGGESTIONS. 

throat  in  particular.  The  neglect  of  an  examination  of  the  throat  has  fre- 
quently been  the  means  of  disseminating  diphtheria.  Many  a  child's  life 
has  been  sacrificed  by  failure  to  make  a  minute  examination  of  the  throat. 

Sleep. — Healthy  infants  normally  sleep  from  eighteen  to  twenty  hours 
out  of  twenty-four.  Thus,  if  infants  are  restless  and  do  not  sleep,  such 
insomnia  denotes  illness. 

Presuming  that  we  have  had  an  opportunity  to  examine  the  infant  dur- 
ing sleep,  let  us  then  have  the  child  undressed  and  notice  the  surface  of  the 
skin ;  it  should  be  mottled,  the  flesh  firm,  the  skin  smooth  and  elastic  to  the 
touch,  and  not  flabby ;  there  should  be  no  impediment  to  the  motion  of  either 
the  arms  or  legs,  they  should  move  freely;  the  joints  should  be  noted  if  they 
are  swollen,  if  large  or  small ;  the  epiphyses  of  the  long  bones  should  be  care- 
fully noted,  and  evidences  of  rickets  determined,  as  this  has  an  important 
bearing  on  various  infantile  diseases. 

I  have  previously  called  attention  to  the  necessity  of  undressing  a  child 
for  its  proper  examination.  Fever  which  cannot  be  explained  may  have  an 
eruption  of  scarlet  fever  on  the  body.  This  can  only  be  detected  by  undress- 
ing and  examining  the  infant. 

Prognosis. 

In  giving  an  opinion  as  to  the  probable  outcome  of  a  given  case,  we 
must  be  guided  by  the  following  conditions :  Has  the  infant  a  good  founda- 
tion— ^been  breast-fed  in  infancy — or  are  we  dealing  with  a  marasmic  or 
rachitic  infant?  The  resistance  offered  to  the  acute  infectious  diseases  by 
an  infant  nursed  at  the  breast  is  most  probably  due  to.  the  antitoxic  virtues 
found  in  the  milk.  The  temperature  should  not  always  be  the  guide. 
Infants  respond  very  quickly  to  disease  and  show  very  high  temperatures. 
They  are  more  susceptible  to  infections  than  adults.  A  high  fever  may 
appear  and  disappear  very  suddenly;  hence  we  should  not  base  our  prog- 
nosis on  the  sudden  appearance  of  temperature.  Tbe  pulse — the  heart 
action — is  our  best  guide  in  estimating  the  outcome  of  a  given  case.  The 
amount  of  food  taken  during  an  illness  and  the  digestion  and  assimilation 
of  the  same  are  important  factors  in  estimating  the  condition  of  the  little 
patient.  Constant  fever,  loss  of  appetite  and  sleep,  with  resulting  heart 
weakness,  should  be  regarded  as  symptoms  of  a  critical  condition. 

Infant  Mortality. 

Through  the  vigilance  of  the  health  department  New  York  City  has 
secured  a  good  milk  supply.  The  feeding  of  impure  milk  was  always  con- 
sidered the  reason  for  the  high  infant  mortality,  especially  during  the 
summer  months.  Although  the  mortality  has  been  reduced  to  23  per  cent., 
there  is  still  room  for  improvement.     The  infant  mortality  in  infections 


X-RAY  IN  DIAGNOSIS. 


15 


diseases  has  also  been  greatly  reduced.  This  is  largely  due  to  the  immuniz- 
ing injections  of  antitoxin  and  the  more  generalized  use  of  antitoxin  as  a 
preventive  measure. 

The  statistics  of  the  mortality  in  diphtheria,  scarlet  fever,  and  measles 
show  a  reduction  in  the  mortality  of  10  to  20  per  cent,  during  the  last 
twenty  years.  The  sanitary  environment  has  changed.  The  beneficial 
change  has  been  largely  due  to  three  factors :  first,  the  better  milk  supply ; 
second,  preventive  measures,  such  as  immunizing  doses  of  antitoxin  to  pre- 
vent diphtheria  after  exposure,  and,  third,  to  fresh  air — this  implies  windows 
open,  new  parks,  roof  gardens,  and  education  of  the  masses  to  a  proper 
understanding  of  the  virtues  of  fresh  air  in  health,  and  especially  in  disease. 

The  public  is  learning  to  appreciate  the  benefits  of  open-air  classes  for 
the  anaemic  children  in  the  public  schools.  Eoof-garden  instruction  and  the 
strict  supervision  of  the  public  schools,  due  to  the  efficiency  of  medical 
inspectors,  have  lessened  contagion  among  school  children.  The  parents 
of  children  suffering  with  adenoids  and  diseased  tonsils  are  notified  and 
advised  regarding  their  danger.  The  open-air  treatment  of  tuberculous 
joints  established  by  the  S.  I.  C.  P.  and  the  sun  therapy  (heliotherapy) 
have  accomplished  excellent  results  at  Coney  Island  and  elsewhere.  Such 
therapeutic  measures  prolong  life  and  reduce  mortality. 


Table  No.  6. — Two  Hundred  Deaths — Their  Mode  of  Feeding  {Louis  Fischer).  In- 
quiry into  200  Deaths,  Taken  at  Random  at  the  Children's  Service  of  the  German 
Poliklinik  and  West  Side  Germa/n  Dispensary. 


Age  in  Months. 

Cases 
Investigated. 

On  Breast 
Only. 

On  Breast 
Partially. 

Bottle  Feeding 
Only. 

0-3    

78 
30 
64 
28 

200 

5 

7 

12 

9 

33 

8 
12 
16 

12 

48 

65 

3-  6   

11 

6-9    

36 

9-12    

7 

119 

The  above  children  were  inhabitants  of  both  the  East  and  West  Side 
of  New  York  City,  living  in  crowded  apartments.  The  hygienic  factor  is, 
therefore,  an  important  one.  Sixty  per  cent,  of  these  children  died  from 
gastric  and  intestinal  disease.  About  30  per  cent,  died  from  catarrhal  dis- 
eases affecting  the  air  passages,  such  as  bronchitis,  pneumonia,  and  tuber- 
culosis.   The  rest  died  from  infectious  diseases  and  surgical  accidents. 


X-RAY  OR  Roentgen  Eay  in  Diagnosis. 

During  the  last  few  years  radiographic  examinations  form  a  most 
valuable  adjunct  to  our  methods  of  diagnosis  in  infancy  and  childhood. 


IQ  DIAGNOSTIC  SUGGESTIONS. 

The  possibility  of  an  instantaneous  exposure  any  time  of  the  day  or  night 
has  minimized  the  difficulty  which  formerly  existed  in  taking  pictures  of 
restless  or  very  sick  children. 

Eadiographic  examination  was  formerly  limited  to  the  bony  struc- 
tures; hence  was  utilized  in  the  diagnosis  and  treatment  of  fractures  and 
dislocations.  In  addition  to  diseases  affecting  the  bony  structures,  it  is 
now  possible  to  differentiate  a  syphilitic  periostitis  from  a  rachitis.  Sub- 
periosteal haemorrhages  and  structural  changes  occurring  in  scurvy  are 
revealed.  An  early,  positive  diagnosis  of  acute  miliary  tuberculosis  with  or 
without  calcification  of  the  glands  can  be  made. 

Stomach  conditions  are  now  universally  studied  by  radiographs  of  the 
alimentary  tract,  after  the  administration  of  some  insoluble  substance, 
as  the  bismuth  salts,  which  obstruct  the  Eoentgen  ray.  Pyloric  spasm  and 
pyloric  stenosis  can  easily  be  differentiated,  the  importance  of  which  is 
apparent,  before  the  aid  of  the  surgeon  is  called. 

Exudations,  effusions,  and  transudations  in  obscure  cases  of  empyema, 
intra-abdominal  or  thoracic  effusions  can  be  diagnosed.  The  presence  of 
obscure  neoplasms,  a  tumor  in  the  brain,  the  spine,  or  in  any  of  the 
larger  viscera  can  be  made  out  with  the  aid  of  the  x-ray.  In  a  case  seen 
recently,  hypernephroma  involving  the  left  kidney  was  easily  located  by 
this  means.  A  calculus  in  the  kidney,  ureter,  or  urethra  is  quickly  located. 
Structural  changes  in  the  bones  and  congenital  defects  hitherto  unsus- 
pected can  be  found. 

In  diseases  of  the  mouth  and  jaw  affecting  the  teeth  or  the  antrum 
of  High  more  and  in  frontal  sinus  infections  we  can  receive  valuable  assist- 
ance. It  is  too  early  to  predict  the  possibilities  of  the  therapeutic  value  of 
the  x-ray,  but  the  diagnostic  aid  rendered  is  indisputable. 


CHAPTER  V. 
GENERAL  HYGIENE  OF  THE  INFANT. 

Hygiene  of  the  Mouth  and  Teeth. 

Mouth. — Care  should  be  bestowed  on  the  mouth  and  teeth.  The  new- 
bom  baby  should  receive  an  occasional  washing  of  its  mouth  with  a  weak 
solution  of  boric  acid  and  water.  This  should  be  done  very  carefully  and 
gently,  or  the  delicate  floor  or  roof  of  the  mouth  will  be  denuded  of  its 
epithelium  and  invite  infection. 

Bednar  directed  attention  to  the  presence  of  aphthae  due  to  trauma- 
tism.    (See  "Bednar's  Aphthae.") 

The  Teeth. — When  teeth  are  present  they  should  be  kept  clean.  It  is 
especially  advisable  to  have  the  teeth  cleaned  with  a  weak  alkaline  solu- 
tion, such  as  bicarbonate  of  soda  in  water.  Neglect  of  the  teeth  will  result 
in  caries  and  foul  breath.  A  dentist  should  be  consulted  if  there  is  the 
slightest  evidence  of  decay.  The  necessity  for  healthy  teeth  is  very  appar- 
ent in  infancy  and  childhood.  A  practical  method  of  cleaning  the  teeth 
of  children  is  to  use  a  pinch  of  table  salt  in  lukewarm  water. 

The  Management  of  the  Navel  (Umbilicus). 
The  Umbilical  Cord.^ 

If  the  child  is  in  a  good  condition  and  is  not  blue  (cyanotic),  and  if 
the  pulsations  of  the  umbilical  cord  have  ceased,  then  the  cord  can  be  tied 
about  one  or  two  inches  from  the  child's  body.  If  the  child  is  feeble  we  can 
gain  by  waiting  for  a  few  moments  as  we  admit  oxygenated  blood  through 
the  umbilical  vessels  into  the  child's  body.  The  point  to  be  remembered 
is  "to  tie  the  cord  if  the  pulsations  therein  have  almost  ceased."  This 
usually  takes  from  two  to  five  minutes. 

Some  authors,  e.g..  Professor  Epstein,  advise  making  a  gauze  pouch 
resembling  a  small  tobacco  pouch  to  tie  the  cord.  This  can  be  easily  ster- 
ilized by  baking  in  an  oven  about  thirty  or  forty  minutes.  Care  must  be 
taken  that  the  heat  is  not  too  great  or  the  gauze  will  be  burnt. 

Do  Not  Use  Oil  or  Salves. — When  salves  or  oils  are  used  they  exclude 
the  air  and  prevent  the  drying  of  the  umbilical  cord,  which  is  so  desirable. 
In  order,  therefore,  to  admit  a  current  of  air  through  the  gauze  to  the  cord. 


^Diseases  of  the  umbilicus — haemorrhages,  etc. — are  described  in  Part  II. 

(17) 


i8  GENERAL  HYGIENE  OF  THE  INFANT. 

nothing  greasy  should  he  used.    The  best  thing  to  use  is  arrowroot  or  corn- 
starch or  a  talcum  powder  containing  1  per  cent,  of  salicylic  acid. 

The  following  two  prescriptions  are  recommended  as  drying  powders : — 

IJ  Talcum 100  grains. 

Salicylic  acid    1  grain. 

Mix  and  apply  thoroughly  every  morning. 

IJ  Talcum 100  grains. 

Boric  acid 1  grain. 

Use  as  above  stated. 

If  the  child's  condition  is  normal  and  healthy  action  takes  place,  then 
the  cord  usually  falls  off  in  about  five  to  ten  days. 

After-treatment. — The'  after-treatment  consists  in  sprinkling  one  of 
the  above-mentioned  drying  powders,  and  covering  the  region  of  the  um- 
bilicus with  several  dry  layers  of  plaim  sterilized  gauze,  over  which  an 
abdominal  binder  should  be  placed. 

An  excellent  powder  is  sold  in  the  shops  under  the  name  of  Velvet 
Skin  Powder.    It  contains  the  following  ingredients : — 

Boric  acid 1        gram. 

Lycopodiimi    0.5     gram. 

Orris  root 7.5     grams. 

Boro-tannate  of  aluminium    0.25  gram. 

Talcum q.  s.  ad  100      grams. 

Veenix  Caseosa. 

The  child  at  birth  is  covered  with  vemjx  caseosa.  It  is  Nature's 
lubricant  to  protect  the  infant  from  the  change  of  temperature  prior  to 
and  after  biirth. 

It  is  advisable  to  lubricate  the  body  with  olive  or  sweet  oil.  This  will 
soften  and  remove  the  vemix  caseosa.  This  can  be  continued  daily  until 
the  cord  has  fallen  off. 


The  First  Bath  of  the  New-borist  Baby. 

The  ease  with  which  an  infection  can  take  place  through  the  umbilicaP 
vessels  accounts  for  most  authors  advising  against  the  first  bath  being  given 
until  the  umbilical  cord  has  separated  from  the  body.  After  the  cord  has 
separated  and  there  is  no  evidence  of  inflammation  or  suppuration  in  the 


*  For  disease  of  the  umbilicus  read  Part  II,  Chapter  on  "Umbilicus; 


Bathing  the  babv.  19 

region  of  the  umbilicus,  then  the  first  bath  may  be  given.    This  is  usually 
about  the  end  of  the  first  week. 


Bathing  the  Baby. 

The  temperature  of  the  bath  for  a  new-bom  baby  should  be  warmer 
than  the  baths  given  as  the  child's  age  progresses.  It  is  advisable  to  bathe 
a  new-bom  baby  in  water  having  a  temperature  between  95°  and  100°  F. 
To  determine  the  temperature  of  a  bath  it  is  necessary  to  have  a  bath  ther- 
mometer.   One  having  a  wooden  casing  is  preferable. 

We  should  never  guess  at  the  temperature  of  a  bath.  Sometimes  a  bath 
that  feels  very  hot  to  a  sensitive  skin  may  not  be  as  warm  as  we  imagine; 
hence,  the  rule  should  be,  ^'depend  on  the  thermometer."  The  temperature 
of  the  bath  should  be  lowered  or  made  cooler  as  the  infant  grows  older. 

The  temperature  can  be  lowered  five  degrees  from  month  to  month  until 
the  bath  is  given  at  a  temperature  of  75°  F.  This  is  a  tepid  bath  which  can 
be  continued  during  both  winter  and  summer  months  for  the  first  year  of 
life. 

Additional  Cleanliness. — It  is  self-understood  that  every  infant  requires 
additional  sponge  baths  to  keep  its  buttocks  and  genitals  clean,  especially 
so  after  each  bowel  movement.  If  a  child  is  properly  washed  or  sponged 
it  is  not  necessary  to  overdo  the  use  of  soap. 

The  Use  of  Soap. — Excessive  use  of  soap  will  provoke  eczema.  Soap 
acts  as  an  irritant  to  the  skin  if  overused.  There  are  some  bland  soaps 
which,  if  used  in  moderation,  will  do  good ;  thus,  the  ordinary  olive-oil 
soap,  commonly  known  as  castile  soap,  or  the  ordinary  glycerine  soap  found 
in  drug  stores  is  very  good.  Medicated  soaps  are  of  no  value  for  a  new- 
born baby  unless  some  special  form  of  soap  is  required  in  a  skin  disease. 

After  the  Bath. — The  child's  body  should  be  thoroughly  dried  and 
powdered,  especially  in  the  folds  of  the  skin  between  the  thighs,  in  the  arm- 
pits, around  the  neck,  the  back,  and  the  abdomen.  We  should  use  powder 
very  liberally,  as  the  dryer  the  skin  is  kept,  the  less  chance  will  there  be  for 
the  development  of  an  eczema. 

Sensitive  Skin. — If  an  infant's  skin  shows  a  tendency  to  be  red  and 
chafed  it  is  advisable  to  use  no  soap  at  all,  but  an  ordinary  bath  or  an 
oatmeal  bath  made  in  the  following  manner  will  be  found  advantageous : — 

Oatmeal  Bath. — How  to  make  the  hath:  Take  between  two  and  three 
pounds  of  good  oatmeal,  and  sew  into  a  bag  made  of  cheesecloth.  Place  the 
.bag  with  the  oatmeal  in  the  infant's  bathtub,  containing  one-half  the  quan- 
tity of  water  to  be  used  for  the  bath.    After  the  bag  has  soaked  for  about 


30  GENERAL  HYGIENE  OF  THE  INFANT. 

one-hall:  hour,  add  enoiTgli  water  to  bathe  the  child's  body  therein.  The 
duration  of  the  bath  shall  be  about  five  to  ten  minutes.  After  the  bath  dry 
the  body  thoroughh'  and  apply  the  following  ointment  wherever  the  skin  is 
tender : — 

IJ.   Calaminaris    5  parts. 

Zinc  ointment   50  parts. 

Apply  with  a  piece  of  clean  gauze  over  the  affected  parts.  Do  not  use 
the  fingers  for  applying  the  salve. 

When  to  Stop  Bathing-. — It  is  advisable  not  to  bathe  if  an  infant  has 
an  eczema  or  a  very  reddened  skin,  and  it  is  a  good  rule  to  follow  never  to 
bathe  if  an  eruption  of  the  body  is  present,  unless  such  eruption  is  due  to 
an  irritation  apjDlied  to  the  skin.  Turpentine,  mustard,  and  camphorated 
oil,  when  rubbed  into  the  skin,  will  cause  an  eruption  resembling  scarlet 
fever.  Under  such  conditions  the  bath  may  be  used;  when  fever  appears 
the  bath  may  be  continued,  providing  there  is  no  eruptive  disease  like 
measles  or  scarlet  fever,  and  then  even  the  baths  may  be  given  if  the  attend- 
ing physician  so  desires.  When  children  have  a  cough  or  during  catarrhal 
manifestations,  it  may  be  advisable  in  some  instances  to  discontinue  the 
bath  for  a  day  or  two.  Great  care  should  be  used  while  bathing  a  child 
suffering  with  vulvo-vaginitis  to  avoid  infecting  the  e3^es. 

Clothing. 

In  ISTew  York  and  similar  climates  children  should  be  comfortably 
clad.  The  body  should  never  he  overheated.  The  trouble  usually  found 
is  that  children  are  coddled  and  their  bodies  overheated  by  an  excess  of 
flannels.  I  have  frequently  had  occasion  to  treat  eruptions  similar  to  the 
lichen  tropicus  which  was  produced  by  an  excessive  amount  of  clothing  and 
consequent  perspiration. 

The  body  should  be  well  protected  in  winter,  and  very  loose,  light 
clothes  should  be  worn  in  summer.  No  infant  should  be  strapped  tightly, 
but  due  allowance  must  be  made  for  respiration  and  for  the  normal  exercise 
of  the  infant,  namely,  by  permitting  freedom  of  the  limbs.  No  pressure 
should  be  permitted  on  any 'portion  of  the  body,  so  that  the  circulation  is 
not  impeded.    Displaced  organs  can  result  from  very  tight  fitting  bands. 

The  Feet. — The  feet  should  always  be  protected.  I  do  not  approve  of 
hardening  infants  by  exposing  their  bare  legs  to  the- peculiarly  changeable 
climate  of  our  Atlantic  coast.  I  have  frequently  found  digestive  disturb- 
ances which  could  be  attributed  to  cold  feet. 

The  usual  shoe  found  in  the  shops,  for  the  new-born  infant,  as  well  as 
the  first  walking  shoe,  are  simply  ornaments  and  not  practical  shoes.  It  is 
advisable  to  devote  at  least  enough  care  to  have  the  shoes  made  on  anatomical 


THE  NURSERY.  21 

lines.  The  accompanying  illustration  (Fig.  7)  shows  the  proper  shape 
for  the  first  walking  shoe. 

The  Abdominal  Band. — The  belly-band  is  a  source  of  great  anxiety  to 
the  mother.  Its  support  is  valuable  for  the  umbilicus  when  the  child  is 
troubled  with  constipation  or  diarrhoea.  It  is  a  valuable  support  for  the 
abdominal  muscles  if  the  child  is  affected  with  whooping-cough.  It  is  not 
necessary  to  wear  the  band  as  an  abdominal  support  more  than  three  months. 
Delicate  infants,  premature  infants,  or  those  suffering  with  gastro-intes- 
tinal  disturbances  may  require  a  supporting  bandage  for  a  much  longer 
time. 

Night  Clothing. — Due  allowance  must  be  made  for  seasonal  changes, 
so  that  light  clothing  should  be  worn  in  summer  and  a  heavier  set  in  winter. 
Eestlessness  will  frequently  be  induced  by  having  the  body  too  warm. 


Fig.  7. — Proper-shaped  Shoe  for  Infant. 


The  Nursery. 


To  develop  an  infant  we  require  fresh  air  and  sunshine.  We  must 
only  compare  a  flower  deprived  of  sunlight  and  air  to  that  which  is  devel- 
oped in  ordinary  healthful  surroundings.  An  infant  should  be  given 
the  best  room  in  the  house,  with  a  southern  exposure.  The  reverse  is  usually 
found;  infants  are  put  into  the  smallest  room,  as  though  they  were  in  the 
way.  The  nursery  should  be  cheerful  and  sunny,  and  have  a  temperature 
ranging  between  66°  and  72°  F.  At  night,  when  the  child  is  well  covered, 
the  temperature  may  be  lowered  to  60°  F.  without  hurting  the  infant. 

Ventilation. — This  is  one  of  the  most  important  matters  to  be  consid- 
ered during  the  development  of  the  infant.  An  infant  should  invariably 
be  removed  from  the  room  in  which  it  has  slept,  and  the  windows  of  the 
nursery  should  be  opened  both  top  and  bottom.  After  proper  ventilation 
the  windows  are  closed  and  the  infant  may  be  brought  back  again.  The 
nursery  should  be  ventilated  at  least  two  or  three  times  a  day. 

When  to  Take  an  Infant  Out  of  Doors. — An  infant  one  month  old 
should  be  taken  out  into  the  fresh  air  in  summer,  sometimes  sooner.  It  is 
understood  that  the  first  few  times  a  child  is  taken  out  of  doors  it  should 
be  taken  into  the  sun,  if  possible,  for  one  or  two  hours.  On  rainy  days  or 
when  it  snows  I  invariably  insist  on  giving  the  infant  air  by  throwing 
open  the  windows  and  dressing  the  child  with  coat  and  cap  as  though  it 


32  GENERAL  HYGIENE  OF  THE  INFANT. 

were  to  be  taken  into  the  street.  This  can  be  done  for  half  an  hour  in  the 
morning  and  afternoon. 

The  Nursemaid. — The  selection  of  a  nurse  is  not  an  easy  matter.  That 
it  is  an  important  matter  we  can  see  when  we  consider  cases  of  tuberculosis 
and  syphilis  that  have  been  unquestionably  transmitted  by  the  nurse  to  the 
child.  My  rule  is  to .  exclude  a  nurse  who  suffers  with  catarrh  or  throat 
trouble.  They  are  a  constant  menace  to  a  healthy  child.  Specific  rules 
should,  be  given  by  the  family  physician  to  each  nurse  regarding  the  feed- 
ing, bathing,  and  general  hygienic  management.  I  invariably  advise  against 
nursemaids  kissing  children  on  the  mouth.  They  should,  never  be  per- 
mitted to  sleep  in  the  same  bed.  I  have  knoAvn  more  than  one  case  of  uro- 
genital discharge  transmitted  to  a  female  infant  in  this  manner.  I  prefer 
a  nurse  between  20  and  40  years  of  age,  one  that  is  quiet,  mild  mannered, 
and  that  does  not  "know  everything."  Experimental  feeding,  as  is  fre- 
quently tried  by  that  miserable  creature  known  as  the  "experienced  nurse," 
is  responsible  for  more  rickets  and  weak  children  than  any  other  method  of 
rearing  children.  It  is  the  mother's  duty  to  consult  the  physician  at  least 
once  a  month  or  oftener  regarding  details  of  feeding,  etc.,  and  it  is  the 
mother's  place  to  instruct  the  nurse.  A  mother  who  is  dejiendent  on  a  nurse 
will  find  that  fact  to  be  a  detriment  to  her  child. 

Method  of  Heating. — An  open-grate  fire  or  a  Franklin  radiator  afford 
the  best  means  of  heating.  Our  city  apartments  in  New  York  are  furnished 
with  steam  heat,  and  a  great  many  have  gas  heating.  These  latter  are  the 
worst  forms  of  heating  and  are  responsible  for  more  catarrhal  affections  of 
the  air  passages  than  anything  else.  I  invariably  advise  the  use  of  a  kettle 
with  steaming  water  to  add  moisture  to  a  room  in  which  a  gas  stove  or  steam 
radiator  is  found. 

The  air  should  be  kept  as  fresh  as  possible;  soiled  diapers  or  soiled 
clothing  should  never  be  dried  in  the  nursery.  Smoking  in  the  nursery 
should  not  be  permitted,  and  kitchen  odors  should  not  be  allowed  to  reach  it. 

Light  at  Night. — To  insure  proper  repose  there  should  be  no  light  and 
no  noise  in  the  nursery.  With  modern  conveniences,  such  as  electricity,  a 
small,  green,  g^ass  bulb  can  be  used  when  a  light  is  necessary.  A  wax  night 
candle  will  answer  for  all  purposes  at  night  if  electric  light  cannot  be  used. 

The  Furniture. — The  simpler  the  furniture  the  better.  The  ease  witli 
which  infants  and  children  contract  measles,  scarlet  fever,  and  diphtheria 
shows  the  necessity  for  plain  furniture  and  no  useless  overhangings.  If  the 
physician  will  explain  to  the  mother  that  pathogenic  bacteria  will  remain 
for  months  in  carpets  and  rugs  and  tapestries,  she  will  understand  why 
simpler  means  are  required.  It  is  advisable,  if  possible,  to  have  a  hai-d- 
wood  floor  which  may  be  scrub1)ed  thoroughly.  All  rugs  should  be  aired 
daily,  and  it  is  safer  to  fumigate  the  same  with  formaline  when  occasion 
requires. 


EXERCISE.  23 

The  Bed  and  Pillow. — A  cradle  that  can  be  rocked  should  never  be 
used  for  a  child.  Nothinj^  worse  than  a  feather  bed  can  be  imagined;  still, 
I  see  them  frequently.  The  best  thing  for  an  infant  to  sleep  on  is  a  hair 
matress,  and  by  all  means  a  hair  pillow. 

Proper  Training. 

From  earliest  infancy  it  is  advisa])lc  to  train  the  baby.  It  should  be 
given  the  breast,  and  after  it  is  through  nursing  or  feeding  from  the  bottle 
it  should  be  laid  in  the  crib.  If  this  habit  is  commenced  early,  a  regular 
habit  of  resting  can  be  formed.  If,  on  the  other  hand,  we  permit  the 
infant  to  sleep  next  to  its  mother's  breast,  it  will  get  into  the  habit  of  being 
fondled  to  sleep.  Bad  habits  will  compel  tlie  mother  to  be  a  slave  to  her 
child,  and  wise  is  she  who  will  accept  the  honest,  well-meant  advice  of  the 
physician  regarding  regularity  in  habits. 

Bowels. — x\n  infant  nine  months  old  can  be  put  on  the  commode.  The 
best  time  for  the  infant's  bowels  to  move  is  after  the  morning  bottle.  In- 
struct, the  mother  to  place  the  child  on  the  chair,  and  if  the  bowels  do  not 
move  naturally,  assist  the  same  by  injecting  about  two  ounces  of  water  to 
which  a  few  spoonfuls  of  glycerine  have  been  added.  This  will  aid  in 
directing  the  infant's  attention  to  its  bowels.  If  the  mother  will  do  this 
regularly  every  morning  the  infant  will  gradually  learn  to  known  for  what 
purpose  it  is  placed  on  the  chair. 

Bladder. — What  is  possible  Avith  the  bowels  can  be  accomplished  with 
the  bladder.  If  the  mother  or  nurse  will  place  th^  infant  on  a  vessel  every 
three  or  four  hours,  the  infant  will  gradually  learn  to  hold  its  urine  until 
such  time.  The  infant  should  be  placed  on  the  vessel  immediately  on  awak- 
ening, be  it  night  or  day.  Children  invariably  empty  the  bladder  on 
awakening. 

Hy^ene  of  the  Nervous  System. — To  develop  an  infant's  brain  the 
nervous  system  requires  quiet  but  cheerful  surroundings.  Useless  excite- 
ment is  harmful.  To  take  an  infant'  and  handle  it  like  a  toy  is  wrong.  I 
have  seen  infants  taken  up  from  a  sound  sleep  to  display  the  "talent"  that 
some  one  had  taught  them.  Nothing  is  more  harmful  than  to  have  the 
mother  compel  her  infant  to  display  various  tricks  during  its  feeding.  While 
this  may  be  a  gi-atification  to  the  friends,  it  certainly  is  detrimental  to  the 
infant's  brain  and  nervous  development. 

Physical  Exercise. 

The  health  of  the  infant  and  child  demands  exercise.  When  this  is 
neglected,  disease  results.  Broadly  spaeking,  there  are  two  forms  of  exer- 
cise— active  and  passive.  There  are  limitations  to  active  exrcise.  In  acute 
febrile  conditions,  rest  is  demanded,  and  all  active  exercise  contraindicated. 
At  such  times,  if  necessary,  massage  may  take  the  place  of  active  exercise. 


24  GENERAL  HYGIENE  OF  THE  INFANT. 

Not  only  in  acute  inflammatory  conditions,  but  also  in  eruptive  diseases,  no 
form  of  active  exercise  should  be  allowed.  Recognizing  the  fact  that 
violent  exercise  results  in  albuminuria,  it  is  very  important  for  the  physi- 
cian-to  prescribe  exercise  and  at  the  same  time  supervise  its  effect  on  the  kid- 
neys by  examination  of  the  urine.  It  is  important  to  bear  in  mind  that  in 
chronic  kidney  disease,  as  in  acute  congestion  of  the  kidney,  or  following 
scarlet  fever  or  typhoid  fever,  the  resulting  strain  from  violent  exercise  may 
do  harm. 

What  has  been  said  concerning  the  kidney  applies  even  more  strongly 
to  the  heart.  After  an  attack  of  scarlet  fever  or  diphtheria,  or  even  after 
pneumonia  or  influenza,  the  effect  of  the  toxin  usually  weakens  the  myo- 
cardium. Exercise  should  therefore  be  prescribed  very  carefully,  and  the 
immediate  effect  c«i  the  heart  noted.  The  effect  on  the  blood-pressure,  on 
the  lungs,  and  on  the  body  is  watched,  so  that  no  strain  is  permitted. 

If  dyspnoea,  fatigue,  or  irregular  heart  action  follows  a  mild  form  of 
exercise,  then  rest — not  activity — is  demanded,  and  here  again  passive 
motions  aided  by  massage  will  be  indicated. 

It  is  a  well-established  fact  in  physiology  that  an  unused  organ  does  not 
develop  properly;  that  a  period  of  long  disuse  leads  to  atrophy;  that  regu- 
lar exercise  of  an  organ  leads  to  its  normal  development  and  growth,  and 
that  organs  that  are  exercised  a  great  deal  are,  in  most  cases,  hypertrophied. 
These  structural  changes  are  associated  with  the  anabolic  effects  of  exercise, 
and  are  most  apparent  in  the  nervous  and  muscular  tissues,  in  the  heart, 
and  in  the  tendons,  ligaments,  connective-tissue  sheaths,  bones,  and  joints 
associated  with  the  voluntary  musculature.  It  seems  to  be  true  also  that,  in 
certain  tissues  at  least,  exercise  not  only  increases  the  size  of.  the  individual 
element  (muscle  fiber,  for  instance),  but  also  increases  the  number  of  the 
tissue  elements  present,  so  that  there  are  more  muscle  fibers  in  the  regu- 
larly exercised  muscle  and  more  nerve  cells  in  the  regularly  exercised  motor 
center  than  in  those  muscles  and  centers  that  are  not  regularly  exercised. 

Associated  with  its  beneficial  influence  upon  general  metabolism, 
physical  exercise  causes  a  general  increase  in  the  functional  efficiency  of  the 
organ.  The  heart  develops  a  greater  strength,  regularity,  and  endurance. 
Circulatory  activities  are  improved.  The  depth  of  inspiration  is  increased. 
The  rhythm  of  respiration  is  slowed.  The  strength,  endurance,  and  co- 
ordination of  the  neuromuscular  elements  controlling  the  movements  of 
respiration  are  improved.  The  necessary  and  very  intimate  co-ordination 
between  the  complex  respiratory  machine,  the  complex  circulatory  machine, 
and  the  complex  vasomotor  machine  is  brought  into  more  perfect  adjust- 
ment and  efficiency.  The  heat  regulation  of  the  body  is  improved.  Diges- 
tion, metabolism,  and  excretion  are  improved. 

The  production  of  active  or  potential  immunity  is  a  function  of  some 
of  the  fixed  and  circulating  cells  of  the  body.    When  pathogenic  organisms 


EXERCISE.  25 

within  certain  limits  of  virulence  gain  access  to  the  tissues  they  are 
destroyed  or  rendered  innocuous  by  one  or  more  of  several  processes.  On 
the  cells  of  the  body  depends  the  exhibition  of  the  phenomena  of  immunity. 
The  degree  of  immunity  produced  is  related  directly  to  the  health  of  the 
cell.  An  impoverished,  poorly  nourished,  unhealthy  cell  will  not  react  to  the 
same  extent  and  with  the  same  success  as  will  the  normal,  healthy,  well- 
nourished  cell. 

The  health,  and,  therefore,  the  immunity-producing  power,  of  the  cell 
depends  upon  its  nourishment,  including  food,  water,  and  oxygen ;  upon  its 
relief  from  the  toxic  influence  of  its  own  waste  products;  upon  its  exercise, 
upon  its  opportunities  for  rest  and  repair,  and  upon  a  reasonable  freedom 
from  the  direct  and  indirect  influences  of  pathogenic  organisms.  The 
health,  and,  therefore,  the  immunity,  of  the  whole  body  depends  upon  the 
health  of  all  its  constituent  parts — on  the  health  of  its  cells.  If  the  cells  are 
all  well  nourished,  active,  and  protected  from  extremes  of  pathogenic  influ- 
ences, their  summated  health  will  be  the  health  of  the  individual  whose 
body  they  in  combination  make.  That  such  a  healthy  individual  is  pos- 
sessed of  a  certain  degree  of  immunity  has  been  proven  empirically  and 
experimentally,  and  it  is  equally  well  established  that  the  possession  and 
conservation  of  the  healthy  body  depend  upon  the  observance  of  several 
simple  hygienic  procedures. 

The  above  statements,  made  by  Dr.  Thomas  A.  Story,  are  founded  upon 
physiological  and  clinical  study.  Exercise  is  demanded  in  health  and  is 
necessary  to  stimulate  metabolism  of  the  food  elements,  and  also  to  aid  in 
the  assimilation  of  food.  External  exercises  are  voluntary  and  are  de- 
manded to  stimulate  the  circulatory,  the  muscular,  and  the  glandular 
systems. 

The  activity  of  the  internal  secretions  depends  on  the  proper  exercise 
of  the  body.  Lack  of  exercise  and  the  lack  of  peristaltic  waves  are  best 
seen  by  the  resulting  constipation. 

In  health  the  variety  and  quantity  of  exercise  indicated  depend  upon 
the  age,  sex,  habits,  physique,  and  conditions  of  the  individual.  The  infant 
must  have  freedom  for  the  kicking,  squirming,  grasping,  and  twisting  move- 
ments that  develop  his  musculature,  incite  and  perfect  his  larger  co-ordina- 
tions, and  stimulate  his  whole  organism  to  normal  functional  activity. 

The  growing  child  continues  these  absolutely  essential  influences 
through  his  play,  games,  and  sports,  and  secures  these  physiological  benefits 
more  or  less  completely  in  spite  of  the  restrictions  of  the  home,  the  school, 
and  urban  life. 

If  the  infant  is  bound  fast,  he  does  not  grow.  If  the  child  is  forced 
to  lead  an  absolutely  sedentary  or  bedridden  life,  he  does  not  develop. 

I  am  indebted  to  Dr.  Thomas  A.  Story,  Physical  Director  of  the  College 
of  the  City  of  New  York,  for  many  valuable  points  in  this  article. 


PART  II. 

ABNORMALITIES  AND   DISEASES  OF  THE   NEW-BORN. 


CHAPTER  I. 


PREMATURE  INFANTS. 


An  infant  bom  before  280  days  of  intrauterine  life  is  called  premature. 
Some  authors  maintain  that  infants  weighing  less  than  4  pounds  should 
be  considered  premature.  If  the  length  of  the  body  is  less  than  19  inches, 
then  we  may  suspect  prematurity.  The  internal  organs,  especially  the  lungs, 
not  being  fully  developed,  we  cannot  expect  normal  functions.  A  premature 
infant  does  not  cry  but  whines.  There  is  muscular  inertia.  The  circulation 
is  very  poor  and  there  is  a  subnormal  temperature  ranging  between  88°  and 
96°  F. 

Children  born  at  six  and  a  half  months  have  grown  up  strong  at  last, 
although  it  is  not  often  they  survive  if  born  before  the  seventh  month.  The 
great  need  of  such  a  baby  is  heat,  and  the  maternity  hospitals  employ  an 
apparatus,  called  a  couveuse,  brooder,  or  incubator,  especially  devised  to 
supply  it.  . 

For  family  use  a  couveuse  may  be  bought  at  the  instrument  makers,  or 
hired  from  some  of  them.  This  is  perhaps  better,  as  the  apparatus  is  costly. 
With  an  increased  degree  of  attention  we  may  get  along  fairly  well  without 
it.  If  a  premature  baby  is  bathed  at  all  after  birth,  the  temperature  of  the 
water  should  be  105°  F.,  and  the  greatest  care  should  be  taken,  while  drying, 
to  see  that  the  child  is  not  chilled.  It  should  be  made  very  warm  by  swad- 
dling it  in  raw  cotton,  head  and  all,  leaving  only  the  face  exposed,  wrapping 
it  about  with  a  blanket,  and  tying  it  around  with  a  roller  bandage.  Hot- 
water  bottles  should  be  placed  on  each  side  of  it  as  it  lies  thus  wrapped  up 
in  its  bed,  and  fresh  ones  substituted  frequently.  A  very  convenient  method 
is  to  place  the  child  in  a  baby's  bathtub  half-full  of  raw  cotton,  in  which  a 
number  of  hot  bottles  have  been  concealed. 

The  infant's  only  clothing  consists  of  a  diaper  and  a  shirt.  The  room 
should  be  kept  warm,  and  especially  so  when  this  human  bundle  is  un- 
wrapped for  its  bath.  After  bathing  it  should  be  rubbed  with  sweet-oil  and 
rolled  up  again  in  fresh  cotton.  Often  it  is  better  to  omit  all  bathing,  and 
simply  rub  with  the  oil.  These  premature  infants  lose  considerably  more 
in  proportion  to  their  birth  weight  than  babies  at  term.  This  is  due  to 
their  immature  digestive  tract;  also  to  the  fact  that  they  are  almost  always 
intensely  jaundiced.  They  gain  very  slowly;  if  at  the  end  of  two  or  three 
weeks  they  have  reached  their  birth-weight,  they  have  done  unusually  well, 
(26) 


THE  CARE  OF  PREMATURE  INFANTS. 


27 


The  incubator  here  described  (see  Fig.  8)  is  the  one  used  at  the 
Sloane  Maternity  Hospital.  There  is  a  great  variety  of  these  incuba- 
tors, but  the  one  made  by  the  Kny-Scheerer  Company  in  New  York 
City  will  answer  all  re- 
quirements. Owing  to 
its  expense,  the  manufac- 
turers will  lend  an  incu-. 
bator  for  a  nominal  sum 
per  month. 

The  apparatus  is 
constructed  of  steel,  with 
glass  doors  and  one  glass 
window  on  the  side  for 
feeding  purposes,  etc. 

The  heat  is  gener- 
ated by  electricity  and 
can  be  regulated  to  any 
desired  temperature.  The 
electric  thermostat  is  sus- 
pended from  the  ceiling 
of  the  chamber.  At  its 
left  end  is  a  thumb- 
screw, which  regulates  the 
amount  of  heat.  Under- 
neath the  cradle  and 
above  the  heater  is  a 
water  pan,  which  should 
be  well  filled  with  water. 
This  is  to  supply  mois- 
ture to  the  air  in  the 
apparatus,  the  amount  of 
which  is  recorded  by  the 
hygrometer  attached  to 
the  rear  wall.  The  air 
supplied  to  the  infant  is 
filtered  through  an  absorb- 
ent cotton  filter.  This  air 
can   be   taken    from    the 


Fig.  5. — Incubator   made   by  the   Kny-Scheerer 
Company,  New  York. 


room  in  which  the  apparatus  is  placed,  or  directly  from  the  outside  by 
means  of  simple  tubes.  The  revolving  wheel  in  the  chimney  indicates  the 
perfect  circulation  of  the  air.  This  apparatus  can  also  be  supplied  with  a 
gas  heat-generator,  the  electric  being  preferred  in  order  to  minimize  the 
contamination  of  the  air. 


38  ABNORMALITIES  AND  DISEASES  OF  THE  NEW-BORN. 

In  some  of  the  babies  the  color  is  poor  from  the  beginning,  and  at  any 
time  they  are  liable  to  attacks  of  cyanosis.  For  these  conditions  a  little 
slapping  to  cause  a  good  cry  or  the  administration  of  oxygen  will  dissipate 
the  blueness.  Often  a  few  drops  of  brandy  in  water  given  every  two  or  threa 
hours  will  prevent  further  trouble.  One  must  be  very  sure,  however,  that 
nothing  has  been  aspirated  into  the  larynx  (Griffith). 

A  great  danger  in  the  care  of  these  babies  is  their  susceptibility  to 
infections.  The  incubator  itself  is  a  great  germ  carrier  and  should  be 
regularly  disinfected.  The  weakness  of  the  lungs  and  gastro-enteric  tract 
makes  the  infant  especially  vulnerable.  Unless  the  air  is  filtered,  dirt  is 
carried  in  continuously;  consequently,  the  streptococcus,  staphylococcus, 
and  pneumococcus  are  always  present,  seeking  an  avenue  of  entrance, 
through  the  skin  in  eczematous  spots  or  in  areas  of  irritation,  at  the  navel, 
through  the  eyes,  nose,  mouth,  larynx,  lungs,  stomach,  and  rectum,  the 
bacteria  can  gain  admission.  To  prevent  infection  the  most  careful  cleans- 
ing is  necessary,  of  both  the  incubator  and  the  baby.  Undoubtedly  most  of 
the  deaths  of  our  cases  could  be  traced  to  this  source. 

A  Danger  of  Incubators. — An  infant  placed  in  an  incubator  was  found 
dead  one  morning,  suffocated  by  vomited  milk  drawn  into  the  lungs.  To 
prevent  this  catastrophe  Wormser  suggests  that  infants  should  not  be  re- 
placed in  the  incubator  until  a  certain  interval  has  elapsed  after  feeding. 
E.  Wormser  (G entralhlatt  f.  Gyn'dhologie,  No.  38). 

Finally,  in  the  carrying  out  of  the  above  essentials  in  the  proper  man- 
agement of  the  premature  infant,  we  require  the  most  patient  and  pains- 
taking attention  on  the  part  of  the  nurse,  and  upon  her  conscientiousness 
depends  the  chance  of  its  survival. 

Eesults. 

The  statistics  are  taken  from  2314  births  which  occurred  at  the  Sloane 
Maternity  Hospital. 

Four  hundred  and  ten  of  these  babies  were  premature,  but  of  these  74 
were  stillbirths,  which  include  macerated  fetuses  and  stillborn  cases  of  pla- 
centa prsevia,  accidental  hemorrhage,  eclampsia,  and  the  like,  leaving  336 
for  treatment. 

Among  these  cases  was  a  set  of  triplets,  and  there  were  18  pairs  of 
twins ;  85  were  treated  as  infants  at  term,  and  of  these  4  died — a  mortality 
of  414  per  cent.;  145  were  put  in  cotton,  and  of  these  12  died — a  mor- 
tality of  8  per  cent.  Some  of  this  class  should  have  been  placed  in  the 
incubator,  but  for  lack  of  room  it  was  impossible ;  106  were  incubator  babies. 

These  are  divided  into  two  classes : — 

1.  Those  that  died  within  4  days  after  birth. 

2.  Those  that  lived  longer  than  4  days. 

Twenty-nine  of  the  incubator  babies  died  within  4  days.     All  of  these 


TLA  IK   II 


Incubator  Bed  designed  by  Dr.  Julius  H.  Hess,  of  Chicago.  Well  adapted  for 
premature  infants.  Its  use  in  tlie  IMichael  Reese  Hospital  has  demonstrated  its 
practical  value.  Cross  section:  -'/,  copper  Avail  covering  asbestos  layer;  9,  stiind 
supporting  bed;  11,  and  I'l,  inner  and  outer  walls  of  copper  water  jacket;  1.2,  asbestos 
layer  insulating  water  jacket;  lo,  water  within  jacket  surrounding  sides  and  floor 
of  bed;  IS,  Avater  gauge;  1!),  ping  in  opening  used  for  filling  jacket;  20,  cock 
for  emptying  jacket;  22,  removable  crib;  2'i,  air  space  underneath  crib;  26,  heating 
plate;   28,  rheostat;  29,  electric  plug. 


THE  CARE  OP  PREMATURE  INFANTS.  29 

were  more  or  less  asphyxiated  at  birth;  i)  were  Ijrcecii  cases,  and  of  tliese  5 
were  difficult  extractions;  []  after  an  accoin/irmfiil  j'<jrrf  in  placenta  prwvia. 
The  rest  were  vertex  })resentations,  and  of  these  2  wei  e  forceps  deliveries ; 
6  were  under  7  months  of  iit^'rine  gestation ;  2'Z  were  between  7  and  8 
months,  and  1,  814  months. 

The  etiology  of  the  premature  lahor  was  an  endometritis  in  14;  sypliilis 
in  2;  albuminuria  in  1;  placenta  previa  in  3;  accidental  ha-morrhage  in 
1;  persistent  vomiting  in  1;  twin  in  1;  violence  in  1,  and  in  4  the  labor 
was  induced.  The  largest  baby  weighed  5%  pounds;  the  smallest  2^e 
pounds.  Only  5  infants  lived  over  24  hours;  24  were  in  such  poor  condi- 
tion at  birth  that  they  survived  only  a  few  hours.  In  16,  autopsies  were 
held,  and  in  all  of  these  there  was  marked  atelectasis;  in  7  there  were 
haemorrhages  of  some  degree,  either  into  the  brain  or  into  the  serous  mem- 
branes; in  2  the  foramen  ovale  was  still  patent. 

Seventy-seven  incubator  infants  survived  the  first  4  days;  51  were 
children  of  primiparse,  27  of  whom  were  out  of  wedlock;  3  infants  were 
under  7  months  of  gestation ;  8  were  over  8  months ;  9  were  breech  presen- 
tations; 1  a  transverse,  and  the  rest  vertices;  2  were  of  triplets  associated 
with  albuminuria;  18  were  in  twin  deliveries  associated  with  albuminuria 
or  hydramnios.  The  cause  of  the  premature  labor  was  endometritis  in  27; 
syphilis  in  4 ;  phthisis  in  2 ;  albuminuria  in  7 ;  accidental  haemorrhage  in 
1 ;  placenta  praevia  in  1 ;  in  2  the  labor  was  induced  for  albuminuria  and 
eclampsia;  1  was  a  Caesarean  section;  another  an  ectopic  gestation  by  a 
laparotomy;  12  were  slightly  asphyxiated  at  birth,  9  moderately  so,  and  5 
deeply  asphyxiated;  2,  after  one  and  one-half  hours'  w^ork  of  resuscitation, 
were  put  in  the  incubator  head  downward,  and  their  condition  w^as  so  poor 
that  they  w-ere  not  expected  to  live,  but  they  left  the  hospital  gaining  in 
weight;  5  weighed  less  than  3  pounds;  38  between  3  and  4  pounds;  33 
between  4  and  5  pounds;  1  over  5  pounds;  the  average  weight  was  3% 
pounds.  During  their  incubator  life  28  had  one  or  more  attacks  of  atelec- 
tasis. All  but  10  were  more  or  less  jaundiced.  The  initial  loss  of  the 
infants  was  from  1  to  17%  ounces;  the  average  was  7  ounces. 

These  figures  are  not  quite  correct,  as  the  babies  were  weighed  at  dif- 
ferent intervals,  some  on  the  fifth  day,  some  on  the  seventh  day,  and  some 
not  until  the  fourteenth  day. 

The  period  of  loss  was  from  5  to  22  days;  the  average  11  days;  10  lost 
steadily  imtil  death ;  1  baby  w^as  in  the  incubator  only  3  days,  wdiile  another 
lived  there  82  days.  The  average  time  w^as  19  days.  Some  were  removed 
early  to  make  room  for  others  who  needed  the  place  more  urgently. 

Only  3  of  the  77  cases  vomited.    The  stools  were  normal  in  32. 

One  was  discharged  from  the  hospital  as  early  as  the  eleventh  day, 
and  others,  also,  too  soon  at  their  mothers'  demand.  One  was  89  days  old; 
the  average  was  24  days. 


30 


ABNORMALITIES  AND  DISEASES  OF  THE  NEW-BORN. 


In  16,  diluted  breast-milk  was  supplemented  at  times  with  a  mixture 
of  cows'  milk  and  water,  with  Russian  gelatine  and  lactose.  In  10,  a  1,  6, 
0.33^  modification  was  used.  In  all  the  rest  diluted  breast-milk  was  relied 
upon.  Twenty-seven  never  nursed  at  the  breast;  of  these  13  died.  A  few 
nursed  as  early  as  the  third  or  fourth  day  two  or  three  times  daily;  others 
not  for  three  weeks,  and  1  not  till  the  sixty-eighth  day.  Of  the  77,  13  died  in 
the  hospital — a  mortality  of  16  per  cent.  The  cause  of  death  was  atelectasis 
and  bronchitis  in  7 ;  acute  asphyxia  from  a  curd  in  the  larynx  in  1 ;  syph- 
ilitic pneumonia  in  1;  cerebral  haemorrhage  in  1;  gastro-enteritis  in  3, 
and  a  patent  foramen  ovale  and  ductus  arteriosus  in  1.  The  condition  of 
3  was  poor  at  the  time  of  discharge,  fair  in  34,  and  very  good  in  37;  33 
were  above  their  birth-weights,  and  57  were  gaining  in  weight.  To  letters 
written  about  January  1,  1900,  no  answer  was  obtained  from  38.  Thirteen 
were  reported  as  having  died;  1  of  these  lived  14  months;  1  lived  4i/^ 
months;  3  lived  3  months;  6  lived  6  weeks;  1  only  a  month.  Pive  of  these 
died  at  the  Nursery  and  Child's  Hospital,  and  3  died  at  Bellevue  Hospital. 
They  were  bottle-fed,  and  the  probable  cause  of  death  was  gastro-enteritis. 

Twenty-one  were  found  to  be  alive  and  doing  well.  Some  had  nursed, 
and  the  others  were  bottle-fed.  The  oldest  baby  was  33  months,  and  almost 
all  were  good,  healthy  children.  One  baby  at  7  months  weighed  16  pounds. 
It  weighed  ^Yiq  pounds  at  birth,  and  nursed  from  its  mother  after  leav- 
ing the  hospital.  The  ectopic  and  the  Csesarean  babies  were  in  beautiful 
condition. 


Table  No.  7. 


« 

At   the   Sloane   Hos- 

Incubators. 

Tarnier. 
Per  Cent. 

Charles. 
Per  Cent. 

Sloane 
Hospital. 
Per  Cent. 

pital.    Not    Counting: 
Those  which  Died  in 
a  Few  Hours. 
Per  Cent. 

Saved  at  6    months 

16 

10 

Saved  at  62  months 

36 

20 

22 

66 

Saved  at  7    months 

49 

40 

41 

71 

Saved  at  7  V  months 

77 

75 

75 

89 

Saved  at  8    months 

88 

70 

91 

Method  of  Feeding. 

The  size  of  the  child  precludes  the  taking  of  an  ordinary  nipple;  hence,, 
various  measures  have  been  tried,  the  most  successful  of  which  has  been, 
according  to  the  author's  experience,  feeding  with  Dr.  Breck's  feeder  for 
premature  infants  (see  Fig.  9).     Feed  at  intervals  of  one  hour,  the  quan- 
tity varying  with  the  age  of  the  infant 


'  Fat,  1 ;  sugar,  G ;  proteins,  0.33. 


THE  FEEDiMG  OF  PREMATURE  INFANTS. 


31 


A  prematurely  born  baby  is  certainly  doomed  without  proper  food, 
and  there  are  so  many  other  factors  to  l)e  considered  during  its  life  in  an 
incubator,  such  as  ventilation,  its  bodily  warmth  and  cleanliness,  that  too 
much  stress  cannot  be  laid  on  the  value  of  its  food.  Without  hread-milk, 
therefore,  I  feel  justified  in  saying:  I  have  yet  to  see  the  premature  infant 
that  iinll  survive,  and  hence  I  advise  procuring  hreast-milk,  containing  no 
colostrum-corpuscles,  but  from  a  woman  having  a  child  anywhere  between 
two  weeks  to  several  months  old,  and  diluting  this  breast-milk,  as  stated 
above,  with  a  solution  of  milk  sugar  or  cane  sugar. 

Voorhees^  says:  "Kegarding  the  care  of  premature  babies  in  incu- 
bators, we  have  relied  mainly  on  diluted  breast-milk,  and  have  only 
employed  diluted  cows'  milk  in  weak  proportions  when  it  was  impossible 


Fig.  9. — Dr.  Breck's  Feeder  for  Pre- 
mature Babies.  Can  be  made  with  a 
medicine  dropper  to  which  a  nipple  is 
attixched. 


Fig.  10.— (a)  Funnel,  (b)  Rubber 
Catheter,  (c)  Glass  Connecting  Tube. 
{(l)    Rubber  Tube  and   Stopcock. 


to  obtain  the  former.  In  our  opinion  our  results  would  have  been  much 
poorer  without  the  help  of  mothers'  milk." 

In  rare  instances,  when  infants  are  very  weak  and  seem  to  doze  and 
will  not  swallow,  they  should  be  fed  with  a  Xo.  8  American  (Tiemann  t^' 
Co.)  rubber  catheter  attached  to  a  rubber  tube  about  one  foot  in  length 
and  ending  in  a  fuimel.     (See  Fig.  10.) 

Very  small  quantities  of  food  should  be  used  in  gavage- feedings  of  the 


'  Archives  of  Pediatrics,  Mav,  1900. 


32 


ABNORMALITIES  AND  DISEASES  OF  THE  NEW-BORN. 


mouth  or  when  feeding  through  the  nose.  No  more  than  4  to  6  drachms 
should  be  used,  and  thus  we  can  feel  our  way.  It  is  a  good  point  to  remem- 
ber that  the  pharynx  being  very  sensitive,  the  irritation  of  the  tube  passing 
into  the  stomach  may  provoke  regurgitation  of  some  of  this  food,  and  fre- 
quently vomiting  will  be  produced. 

Baby  M.,  born  March  31,  1909,  was  sent  by  Dr.  I.  L.  Hill  to  my  service  in 
the  Babies'  Wards  of  the  Sydenham  Hospital.  The  weight  at  birth  was  five  pounds 
two  ounces.  The  feeding  consisted  of  mother's  millc  three  drachms  diluted  with 
barley  water  three  drachms.      On  April  2d,  when  three  days  old,  the  weight  was 


SYDENHAM    HOSPITAL 

WEIGHT  CHART  Dak  of  Sm 


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Fig.   11. — Birth:  | Placed  in  Incubator;  | Removed  from  Incubator. 

five  pounds.  The  infant  could  not  retain  the  diluted  human  milk,  there  Avas  con- 
siderable projectile  vomiting.  Condensed  milk  was  then  given.  Condensed  milk 
V2  drachm  to  two  ounces  of  sterile  water.  One-half  ounce  was  given  at  each  feed- 
ing. This  food  was  retained  but  the  infant  emaciated  and  its  lowest  weight  was 
four  pounds.  Gavage  was  resorted  to  at  every  other  feeding.  The  vomiting  became 
less  and  the  weight  increased,  the  infant  gaining  slowly.  The  extremities  were  cold. 
The  infant  was  cyanosed  and  was  placed  in  an  incubator.  It  then  weighed  four 
pounds  four  ounces.  As  the  weight  remained  stationary  for  one  week,  the  condensed 
milk  feeding  was  discontinvied  and  two  drachms  of  the  following  formula  were 
given:  Cows'  milk,  30.0;  barley  water,  50.0;  peptogenic  milk  ])Owder,  V3  measure. 
The  infant  gained  ra])idly,  vomited  less,  and  slept  longer.  Whenever  possible 
we  procured  woman's  milk  and  substituted  it  for  the  cows'  milk  feeding.  The 
dnfant  remained  in  the  incubator  twenty-seven  days,  and  Avas  removed  Aveighing 
six  pounds  seven  ounces. 


'11  IK   FEEDIN(i^  OF   I'REMATURE  INFANTS.  33 

S 

The  HlooJ. — From  incooiiiiiin  ;il  l)irth,  the  stool  {gradually  become  a  grass-green, 

jelly-like   mass;     Inter    it   was    a  yellowish-green,   saponified   stool.      The    first  three 

weeks   the   infant  was   constipated.      This    constipation   later   improved   so    that   the 

stool  was  softer,  pasty  in  consistency,  and  yellowish  or  yellowish-green  in  color.     The 

infant   grew    and    developed   and    was    discliarged    in    June,    1009,    weighing    eleven 

pounds. 

Serum  Injections. — The  subcutaneous  injection  of  sterile  horse  serum  was  com- 
menced with  the  idea  of  promoting  nutrition.  About  15  cubic  centimeters  were 
injected  into  the  loose  cellular  tissue  of  the  abdomen,  and,  when  it  was  found  that 
it  Avas  completely  absorbed,  a  daily  injection  of  15  cubic  centimeters  was  ordered. 
Later  30  cubic  centimeters  Avere  injected  and  absorb, d.  Xo  febrile  reaction  fol- 
lowed such  injection.  Although  many  dozens  of  these  injections  were  given,  with  the 
usual  aseptic  precautions,  not  once  did  an  abscess  or  other  sign  of  infection  occur. 

The  gradual  daily  increase  in  weight  was  attributed  in  some  measure  to  this 
mode  of  treatment. 

Skimmed  milk  has  given  me  excellent  results  in  a  series  of  premature 
infants.  Whenever  possible  the  mouth  feeding  was  supplemented  by  hypo- 
dermoclysis  consisting  of  2  ounces  of  normal  saline  solution,  temperature 
103°  F.,  injected  twice  a  day  into  the  loose  cellular  tissue  of  the  abdomen. 

A  close  study  of  the  details  required  in  the  successful  rearing  of 
undersized  infants  shows  that  the  following  points  are  helpful : — ■ 

1.  Vomiting,  if  present  after  feeding,  means  longer  interval  between 
meals. 

3.  An  undeveloped  and  weak  infant  taking  hut  several  drachms  from 
a  medicine  dropper  will  be  better  fed  by  gavage.  Most  of  my  success  has 
been  due  to  gavage  at  regular  intervals  night  and  day. 

3.  The  temperature  of  the  infant  is  usually  subnormal.  In  addition 
to  placing  the  infant  in  an  incubator,  I  have  its  body  well  oiled,  especially 
the  feet,  and  the  infant  wrapped  in  cotton.  The  heat  of  the  incubator 
produces  dryness  of  the  mouth  and  lips,  therefore  water  is  given  frequently 
by  spoon  or  medicine  dropper. 

4.  To  aid  metabolism  and  to  assist  the  bowels,  an  injection  of  a  table- 
spoonful  of  warm  sweet  oil  into  the  rectum  helps  to  move  the  bowels.  The 
weight  should  be  taken  daily,  and  it  is  important  to  increase  the  percentage 
composition  of  the  food  until  the  infant  gains  in  weight. 

5.  The  great  danger  of  exposure  prohibits  the  daily  bath,  hence  the 
infant  should  be  cleansed  by  inunctions  with  warm  oil. 

The  Incuhator. — The  strict  supervision  of  an  incubator  demands  two 
trained  nurses,  The  heat  must  be  regulated.  The  thermometer  on  the 
inside  of  the  incul)ator  must  frequently  be  observed  and  the  moisture 
properly  regulated,  so  that  the  air  in  the  incul)ator  is  not  too  dry. 

As  a  rule,  an  incubator  infant,  if  otherwise  healthy,  shows  restlessness 
when  its  feeding  time  arrives.  The  infant  is  taken  from  the  incubator,  the 
doors  of  the  incubator  are  closed  to  retain  the  heat,  the  infant  is  rapidly 
fed  by  gavage  or  the  feeder,  and  returned  to  the  incubator. 

3 


CHAPTEE  II. 

PROPHYLAXIS  AND  TREATMENT  OF  THE  EYES  IN  THE  NEW-BORN. 

The  vaginal  discharge  of  a  pregnant  woman  contains  pathogenic  bac- 
teria. This  frequently  gives  rise  to  an  infectious  catarrh  in  the  new-born. 
It  is  therefore  important  to  treat  the  eye  of  the  new-born  baby  with 
extreme  care  to  prevent  an  infection  which  can  produce  serious  results. 

Teeatment  of  the  Eyes  in  the  JSTew-borkt. 

Ordinarily  the  eyes  should  be  washed  with  a  pledget  of  sterilized  cotton 
dipped  in  plain  sterile  water  or  a  2  per  cent,  boric  acid  solution.  The 
mouth  and  nose  should  be  similarly  treated.  All  cotton  used  for  the  hygiene 
of  the  mouth,  nose,  and  eyes  should  be  burned  immediately  after  use. 

Crede  advises  the  use  of  a  1  per  cent,  solution  of  nitrate  of  silver. 
One  drop  (no  more  than  one  drop)  is  allowed  to  drop  from  a  solid  glass 
rod  or  a  medicine  dropper  on  the  center  of  the  cornea.  Its  object  is  to 
prevent  the  infant  from  acquiring  ophthalmia  neonatorum. 

The  prophylaxis  of  blindness  is  worth  stvidying.  The  New  York 
Association  for  the  Blind  reports  many  cases  "of  needlessly  blind  victims 
of  ophthalmia  neonatorum."  The  official  census  of  the  blind  for  the 
State  of  New  York  for  190G  gives  a  total  of  6200,  out  of  which  number 
1984  were  preventable  blindness,  most  of  them  caused  by  ophthalmia 
neonatorum. 

Garrigues^  states  that  in  lying-in  asjdums  before  this  treatment  Avas 
adopted,  purulent  ophthalmia  was  very  prevalent. 

Statistics  show  that  one-half  to  two-thirds  of  those  affected  with 
blindness  lost  their  sight  from  this  cause. 

When  the  frequency  of  the  gonococcus  in  the  vaginal  secretions  of 
women  delivered  in  lying-in  asylums  is  considered,  then  the  wisdom  of 
prophylaxis  cannot  be  questioned. 

Of  late  protargol  (10  per  cent,  solution)  has  been  subs^tituted  for  the 
nitrate  of  silver  solution.     It  is  just  as  effective  and  less  irritating. 

Solution  argyrol  (20  per  cent.)  is  very  useful  in  the  catarrhal  affec- 
tions of  infants  and  children.  I  have  seen  very  good  results  during  my 
service  at  the  Willard  Parker  Plospital  with  the  same.- 


1  Henry  J.  Garrigues:     "Textbook  of  Obstetrics,"  1902. 
^  See  also  Part  X,  "Diseases  of  the  Eye." 

(34) 


CHAPTER  III. 

DISEASES  AND  MALFORMATIONS  OF  THE  UMBILICUS. 

Granuloma. 

A  MASS  of  fungus  or  exuberant  granulations  is  frequently  found  in 
the  umbilicus.  Sometimes  the  granuloma  resembles  a  large  red  bead.  It 
is  usually  seen  after  the  cord  has  separated.  A  discharge  usually  oozes. 
These  granulations  bleed  very  easily. 

Treatment. — The  application  of  a  solid  stick  of  nitrate  of  silver  to 
thoroughly  destroy  the  granulations  is  usually  all  that  is  required.  If  these 
granulations  persist  then  the  same  can  be  removed  with  the  aid  of  a  sharp 
curette  by  simple  scraping,  after  which  a  dusting  powder  like  europhen 
should  be  used. 

Diphtheritic   Omphalitis. 

The  new-bom  baby  is  occasionally  infected  with  diphtheria.  If  there 
is  an  omphalitis  the  Klebs-Loeffler  infection  can  easily  be  transmitted.  The 
following  case  was  seen  by  me  in  consultation : — 

A  child  4  years  old  suffered  with  diphtheria  of  the  upper  air  passages,  -which 
finally  spread  to  the  larynx,  necessitating  intubation.  This  family  lived  in  a 
crowded  apartment.  The  mother  gave  birth  to  an  infant  five  days  later,  and  was 
herself  infected  with  diphtheria  of  the  vagina  and  vulva.  Her  new-boi'n  baby 
was  about  six  days  old  when  I  first  saw  it.  The  umbilical  cord  had  just  sloughed 
away.  The  region  of  the  umbilicus  was  highly  inflamed  and  covered  with  thick 
pseudo-membranes.  The  child  died  on  the  eleventh  day,  of  septicaemia.  A  culture 
taken  showed  Klebs-Loeffler  bacilli.  The  physician  that  attended  this  family  told 
me  that  the  nurse  in  charge  of  the  older  child  with  laryngeal  diphtheria  also  nursed 
the  mother  and  the  new-born  baby.  He  believed  that  the  infection  was  undoubtedly 
carried  by  the  nurse. 

Treatment. — Saturate  a  piece  of  sterile  gauze  with  antitoxin  and  apply 
to  the  umbilicus.  Eemoisten  every  hour,  applying  fresh  gauze  three  times  a 
day.  '  Give  an  intramuscular  injection  of  1000  antitoxin  units.  Give  ^o 
grain  calomel  twice  a  day  for  three  days. 

The  Dangers  Incident  to  Carelessness  in  Handling  the  Navel. 

If  through  some  accident  the  ligatures  around  the  umbilical  cord 
should  slip,  and  blood  oozes  from  the  wound,  fatal  hgemorrhage  can  result. 
The  attention  of  the  physician  should  at  once  be  directed  to  this  condition. 
This  can  become  a  very  serious  matter  if  neglected ;  hence  it  is  of  the  utmost 
importance  to  remedy  it  at  once.     The  neglect  of  such  things,  besides  the 

(35) 


36 


DISEASES  AND  MALFORMATIONS  OF  THE  UMBILICUS. 


improper  bandaging  or  uncleanliness  in  this  region,  is  liable  to  cause  not 
only  convulsions,  but  blood  poisoning  and  death. 


Fig.  12. — Case  of  Omphalocele  admitted  to  the  Babies'  Wards  of  the 
Sydenham  Hospital.  A  semi-globular  tumor  4  inches  in  diameter,  and 
2V2  inches  above  level  of  the  body.  The  stump  of  the  umbilical  cord  is 
seen  on  the  left  side  of  the  tumor.  Sterile  gauze  dressings  were  applied. 
After  several  weeks  the  mass  gradually  sloughed  off  and  the  wound  closed. 
( Original. ) 


Tig.   13; — Appearance  of   abdomen    four   weeks   after    treatment.      Case 
was  discharged  cured  when  six  weeks  old.     (Original.) 

Septic  Omphalitis. 
An  infant  was  seen  by  me,  through  the  courtesy  of  Dr.  S.  Straus,  in 
this  city  during  the  summer  of  1902.    History,  as  follows : —  • 

It  was  the  first  child  born;  no  previous  miscarriage;  family  history  excellent; 
no  history  of  syphilis;  labor  was  easy,  and  baby  was  born  in  natural  manner. 
The  mother  was  in  excellent  health;  had  milk  in  both  breasts;  normal  temperature. 
Asepsis  was  thoroughly  carried  out.  The  infant  had  a  temperature  of  103°  F.,  in  the 
rectum,  slight  gastroenteric  complication,  greenish,  colicky  stools;  the  umbilicus 
was  inflamed  and  excoriated;  slight  evidence  of  pus. 

Diagnosis. — Septic  omphalitis  due,  probably,  to  infection  by  the  nurse  with  un- 
clean hands  while  dressing  the  umbilicus. 

Treatment. — Strict  asepsis  to  be  followed.     The  umbilicus  to  be  washed  with 


CONGENITAL  OBLITERATION  01''  THE  BILE  DUCTS. 


37 


1  to  2000  bichloride  of  mercury.  Sterile  gauze  and  aristol  or  some  drying  powder 
applied.  The  stomach  and  bowels  were  cleansed  with  calomel,  and  the  infant  fed 
every  two  hours  at  its  mother's  breast.  The  child  made  an  excellent  recovery  in 
about  four  or  five  days. 

Meckel's  Diverticulum. 
A  condition  wliicli  may  at  first  simulate  umbilical  polypus,  and  for 
which  umbilical  ])olypus  may  be  a  symptom,  is  the  persistence  of  a  Meckel 
diverticulum.  This  consists  of  the  persistence  of  a  piece  of  intestine, 
usually  patent,  connecting  the  small  intestine  with  the  umbilicus.  It  rep- 
resents a  vitelline  duct  that  failed  to  atrophy  when  the  placental  circulation 
became  established,  and  betrays  its  presence  by  an  escape  of  fasces  from  the 
umbilicus.    It  is  a  rare  malformation  (Eotch). 


r^ 


Fig.  14. — Illustrating  Effects  of  the  Persistence  of  the  Omphalomesenteric 

Duct    and   Formation    of    the    So-called    Diverticulum    Tumor     (Riesman). 

1.  The  omphalomesenteric  duct  shown  as  an  opening' leading:  from  the  umbilicus  to  the 
ilium.  2.  Showing'  a  small  portion  of  the  proximal  intestinal  wall.  This  may  happen  in  a 
constipated  child,  while  straininsr  at  stool.  The  same  condition  may  occur  during  a  par- 
oxysm of  whooping-cough,  3.  The  tumor  is  much  larger,  frequently  sausage-shaped.  It 
is  irreducible. 

CONGETNITAL    OBLITERATION    OF    THE    BiLE-DUCTS. 

This  condition  has  been  carefully  studied  by  John  Thomson,  of  Edin- 
burgh. He  has  tabulated  his  studies  in  his  book  on  "Congenital  Oblitera- 
tion of  the  Bile-ducts,"  1892. 

Etiology. — There  can  be  no  doubt  that  various  malformations  of  the 
liver  and  bile-ducts  do  occur  which  are  certainly  of  this  nature.  For 
example,  congenital  a-bsence  of  the  gall-bladder  has  been  frequently  de- 
scribed, and  some  of  the  cases  were  due  to  arrest  of  development,  although 
many  were  probably  of  inflammatory  origin.  Wenzel  Gruber  has  published 
a  case  in  which  a  forked  cystic  duct  was  fouiid,  and  Konitzky  has  described 
another  in  which  the  common  duct  had  an  unusualty  long  and  curved! 
course,  and  opened  into  the  middle  of  the  horizontal  portion  of  the  duo- 
denum, its  lumen  being  narrow^ed.  0.  Witzel  also  has  published  notes  of 
an  infant  boiTi  with  a  large  number  of  congenital  abnormalities,  in  whom, 
in  addition  to  hemicephalus,  situs  viscenim  inversus,  six  fingers  on  each 
hand,  etc.,  there  was  a  cystic  condition  of  the  liver  and  complete  imper- 
meability of  both  the  cystic  and  common  ducts.  Other  developmental 
defects  have  been  obsei-ved,  namely,  in  Heschl's  absence  of  the  bile-ducts  in 


38  DISEASES  AND  MALFORIHATIONS  OF  THE  UMBILICUS. 

the  liver-tissue,  and  in  Professor  Simpson's  want  of  the  spigelian  and  quad- 
rate lobes. 

The  frequency  with  which  this  exceedingly  rare  condition  affects  sev- 
eral members  of  the  same  family  is  very  strongly  in  favor  of  this  view,  and, 
indeed,  it  seems  difficult  to  explain  it  otherwise.  It  has  been  suggested  that 
this  reappearance  of  the  disease  in  the  same  family  might  be  explained  by 
supposing  a  common  syphilitic  taint.  This  suggestion,  however,  cannot  be 
accepted,  for  we  never  find  a  tendency  for  an  extremely  rare  manifestation 
of  syphilis  to  recur  four  or  five  times  in  a  family  without  any  of  the  com- 
mon s}Tiiptoms  of  that  disease  being  present  at  the  same  time. 

Pathology. — ^The  liver  is  usually  found  much  enlarged,  of  a  very  tough 
consistency — due  to  biliary  cirrhosis — and  of  a  dark  green  color,  owing  to 
tlie  presence  of  numerous  masses  of  inspissated  bile  in  the  small  bile-ducts. 
In  the  great  majority  of  cases  there  is  complete  obliteration  of  some  part 
or  parts  of  the  hepatic,  common  or  cystic  ducts,  or  of  the  gall-bladder, 
while  with  very  few  exceptions,  implication  of  the  blood-vessels  or  other 
tubes  in  the  neighborhood  is  conspicuous  by  its  absence. 

Pathology  of  the  Lesion  of  the  Ducts. — The  lesion  has  been  ascribed 
to  three  different  morbid  processes,  either  acting  separately  or  in  combina- 
tion, namely: — • 

1.  Peritonitis  and  its  results ^  acting  on  the  ducts  from  outside,  and 
either  compressing  them  or  being  a  source  of  inflammatory  action,  which 
spreads  afterward  to  their  walls. 

2.  An  inflammatory  or  other  lesion  of  the  ducts  themselves. 

3.  An  arrest  or  defect  of  development. 

And  further,  various  predisposing  causes  have  been  described  as 
accounting  for  these  morbid  processes,  namely : — 

1.  Congenital  syphilis. 

2.  Digestive  distu7'hance  on  the  part  of  the  parents. 

3.  Injuries  or  exposure  to  cold,  either  of  the  mother  or  child. 

4.  Erysipelas  of  the  child. 

Symptoms. — Such  children  are  jaundiced  at  birth  or  they  become  so 
within  the  first  week  or  two  of  life;  otherwise  they  are  healthy  and  well- 
nourished.  In  some  cases  there  is  meconium  followed  by  colorless  motions ; 
in  others  the  faeces  are  devoid  of  color  from  the  very  first.  The  urine  is 
deeply  bile-stained.  The  jaundice  is  of  a  dark  greenish  tinge,  and  lasts  till 
death,  and  the  motions  remain  colorless.  A  certain  proportion  of  the 
children  die  from  umbilical  hjemorrhage  within  the  first  fortnight,  and,  of 
those  who  survive  this  period,  a  large  number  suffer  from  spontaneous  haem- 
orrhage from  other  situations.  The  liver  steadily  enlarges,  and  the  spleen 
also.  After  living  some  months  the  children  become  more  or  less  emaciated. 
Spasms  often  supervene,  and  death  ensues  in  the  end  m  a  state  of  exh^stioxj. 
from  some  trifling  intercurrent  disease. 


CHAPTER  IV. 

H.EMORRHAGIC  DISJOASES  OF  TllK  NEW-BORN. 

Spontani:ous  ILemoium  i age. 

The  occurrence  of  spontaneous  luumorrliages  is  one  of  the  most  char- 
acteristic clinical  features  in  these  cases.  In  the  cases  collected  by  Thomson, 
in  21  out  of  the  50 — that  is,  in  almost  half  of  the  cases  which  lived  more 
than  a  few  da3's — the  fact  of  hii'morrhages  having  occurred  from  some  part 
of  the  body  is  noted,  and  in  all  probability  it  may  have  occurred  in  some 
of  the  others  also,  although  not  mentioned,  as  the  records  of  many  of  them 
are  so  meager. 

The  situations  of  the  haemorrhages  mentioned  in  Thomson's  collection 
are  as  follows  : — 

Subcutaneous in  7  of  the  cases. 

Subconjunctival     in  1  of  the  cases. 

Umbilical    in  6  of  the  cases. 

From  nose    in  2  of  the  cases. 

Vomited    in  4  of  the  cases. 

From  bowel   in  8  of  the  cases. 

From   mouth    in  1  of  the  cases. 

From    lung    in  1  of  the  cases. 

Into  gall-bladder    in  1  of  the  cases. 

From   leech-bite    (excessive)  .in  1  of  the  cases. 

A  tendency  to  bleed  is  found  in  many  children.  In  the  preceding 
chapter  I  have  described  haemorrhage  as  a  symptom  of  congenital  oblitera- 
tion of  the  bile-ducts.i  I  have  also  described  a  very  serious  haemorrhage  in 
a  case  of  congenital  syphilis  (see  chapter. on  ''Syphili,s")  which  ended  fatally. 
Direct  infection  through  the  umbilical  vessels  is  a  frequent  cause  of  pyaemia, 
and  this  same  can  result  in  haemorrhage. 

Etiology. — Eitter-  studied  190  cases.  Of  these,  2-i  were  associated  with 
sepsis.  Kilham  and  Mercelis^  describe  haemorrhages  in  10  cases  out  of  54. 
It  seemed  that  these  M^ere  all  due  to  one  and  the  same  pyogenic  infection. 

Gaertner*  describes  a  short  bacillus  which  he  isolated  from  two  -cases 
resembling  the  colon  bacillus.  When  the  same  was  injected  into  the  perito- 
neum  of   animals,   a   disease  was  produced   accompanied  by   htemorrhage 

^  Read  article  on  "Haemorrhages  in  Congenital  Obliteration  of  the  Bile-duct," 
page  35. 

"Oest.  Jahrbuch  fiir  Pediatrik,  1871,  p.   127. 
'Archives  of  Pediatrics,  March,   1899. 
?  Archly  fiir  Kinderheilkunde,  1895. 

(39) 


40  HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

similar  to  that  seen  in  the  new-bom.  Holt  describes  a  case  in  which 
cultures  were  taken  by  Dr.  J.  J.  Mapes  from  which  a  bacillus  resembling 
that  described  by  Gaertner  was  isolated.  The  absence  of  a  sufficient  quan- 
tity of  calcium  in  the  blood  was  supposed  to  be  the  prime  cause  of  haemor- 
rhage. This  has  been  disproven  by  the  recent  work  of  Addis. ^  Sahli  and 
more  recently  Morawitz  and  Lessen  have  shown  that  the  disease  hemo- 
philia may  be  due  to  deficiency  of  thrombokinase. 

Pathology. — Small  or  large  extravasations  of  blood  may  be  found  upon 
the  various  internal  organs  affected.  The  brain,  the  thymus  gland,  the 
stomach,  the  bowels,  the  pericardium,  the  pleura,  and  peritoneum  may  have 
ecchymoses  upon  their  surfaces.  A  frequent  source  of  haemorrhage  is  the 
presence  of  ulcers.    Gastric  and  intestinal  ulcers  are  by  no  means  rare. 

Symptoms. — The  first  symptom  noticed  is  the  presence  of  blood.  This 
may  be  present  in  the  vomit,  in  the  stool,  or  in  the  urine.  There  may  be 
an  oozing  beneath  the  skin  or  from  the  umbilicus.  The  bleeding  does  not 
amount  to  a  very  large  quantity.  The  infant  is  usually  very  anaemic.  The 
pulse  is  small  and  feeble.  The  body  is  emaciated.  The  temperature  fluc- 
tuates ;  as  a  rule,  it  is  subnormal,  although  it  may  be  very  high.  The  course 
of  the  disease  is  short ;  the  bleeding  usually  ceases  in  a  few  days. 

Umbilical  Hemorrhage. 

Improper  tying  of  the  ligature  around  the  umbilical  cord  or  trau- 
matism frequently  causes  a  slight  oozing.  These  oozings  are  very  easily 
controlled  by  the  application  of  a  proper-fitting  ligature.  When,  however, 
a  spontaneous  haemorrhage  occurs  it  may  be  impossible  to  arrest  the  same 
with  ordinary  means.  In  these  cases  the  haemorrhage  occurs  without  pre- 
vious warning.  As  a  rule,  the  umbilicus  has  been  perfectly  normal  for  a 
few  days  prior  to  this  haemorrhage.  Some  authors  state  that  it  may  be 
fatal  in  less  than  twenty-four  hours. 

Hemoglobinuria  Neonatorum  (Winckel's  Disease). 

Considerable  has  been  written  upon  this  obscure  condition,  which  is  very 
rarely  met  with  in  the  new-born  baby.  As  a  rule,  this  condition  is  seen  as 
an  epidemic  in  a  maternity  hospital.  Winckel  reports  19  deaths  out  of 
23  cases. 

Pathology. — Haemorrhages  are  found  in  various  organs.  The  lungs  are 
black.  The  bladder,  the  spinal  canal,  the  liver,  and  the  spleen  all  show 
darkened  secretions.  The  kidneys  are  dark  colored.  All  observers  state 
that  the  umbilical  vessels  are  not  involved. 

Symptoms. — The  skin  of  the  body  has  a  peculiar  icteric  or  bronzed 
appearance.     The  palms  of  the  hands  and  soles  of  the  feet  have  a  bluish 


*  Quarterly  Jour,  of  Medicine,  Jan.,  1909. 


GASTROINTESTINAL  HEMORRHAGE.  41 

or  purplish  color.  The  conjunctiva  has  an  icteric  appearance.  The  stool 
is  blackish  or  greenish.  The  urine  is  dark  and  contains  blood ;  it  is  thick 
and  sometimes  resembles  syrup.  There  is  no  fever.  The  pulse  is  very  rapid. 
Convulsions  and  squinting  are  usually  seen.  There  is  a  rapid  diminution  in 
the  blood  cells,  from  5,700,000  one  day  to  3,400,000  on  the  third  day. 
These  cases  end  fatally,  as  a  rule. 

Acute  Fatty  Degeneration  of  the  Nevt-born  (Buhl's  Disease). 

When  an  infant  is  born  in  an  asphyxiated  condition  and  there  is  asso- 
ciated umbilical  haemorrhage,  then  an  infection  of  pathogenic  bacteria  may 
take  place.  In  some  respects  this  disease  resembles  Winckel's  disease.  In 
both  w^e  have  haemorrhages  as  well  as  fatty  degeneration  of  the  internal 
organs.  The  symptoms  are  a  bleeding  from  the  stomach  and  bowels,  asso- 
ciated with  jaundice.  In  Buhl's  disease  we  have  bleeding  from  the  um- 
bilicus. 

Gastro-intestinal  Hemorrhage  (Melena). 

Dark-colored,  tarry  stools  are  the  usual  symptoms  of  melaena.  The 
black  stool  may  also  contain  clots  of  blood.  A  crucial  test  for  the  presence 
of  blood  in  examining  the  faeces  for  the  presence  of  blood-corpuscles  is  the 
microscope.  Normally,  meconium  does  not  contain  blood.  Another  symp- 
tom is  the  vomiting  of  dark-brown  liquids;  occasionally  bright-red  blood 
may  be  present. 

Haemorrhages  of  the  mouth  and  nose  are  generally  due  to  syphilis, 
although  ulcerative  conditions  may  cause  local  haemorrhage.  When  pem- 
phigus or  furunculosis  is  present,  haemorrhages  frequently  occur.  Haemor- 
rhage from  the  female  genital  organs  may  occur  as  well  as  from  any  other 
part  of  the  body.  They  are  usually  associated  with  catarrhal  inflammation 
of  those  parts. 

Diagnosis. — This  is  usually  very  easy,  especially  if  the  bleeding  is 
superficial.  The  diagnosis  is  difficult  when  an  obscure  place  like  the  intes- 
tine is  the  source  of  the  haemorrhage.  The  microscope  will  usually  aid  in 
establishing  a  diagnosis  of  blood  in  the  excreta.  When  the  bleeding  is 
confined  to  the  mouth  and  nose,  syphilis  should  be  suspected. 

Prognosis. — A  careful  prognosis  should  always  be  given,  although  the 
disease  is  not  necessarily  fatal.  Townsend  studied  709  cases  and  recorded 
a  mortality  of  79  per  cent. 

A  male  infant,  six  days  old,  was  seen  by  me  through  the  courtesy  of  Dr.  A. 
Goldwater.  The  child  had  vomited  several  times.  The  vomit  contained  blood  of  a 
bright-scarlet  color.  The  stool  had  been  yellowish,  but  now  is  black  and  tarry. 
There  was  a  slight  oozing  of  blood  from  the  umbilicus.  When  I  applied  some 
absorbent  cotton  to  the  umbilical  stump,  bright-scarlet  blood  was  seen.  The 
infant  was  well  nourished  and  was  nursed  by  its  mother.  The  diagnosis  of  melaena 
l^eQnatorum  was  made  by  the  attending  physician  and  I  agreed  in  the  diagnosis. 


42  HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

The  treatment  consisted  in  the  application  of  a  solid  stick  of  nitrate  of  silver 
to  the  umbilicus,  and  strict  aseptic  dressing.  The  haemorrhages  were  probably  due 
to  pyogenic  infection. 

Treatment. — Umbilical  hsemorrhage  can  best  be  controlled,  as  above 
cited,  by  the  application  of  a  solid  stick  of  nitrate  of  silver  followed  by  a 
dusting  powder,  such  as: — 

T^  Aristol, 

Alum  usta , aa  3ij,  or  8.0 

Sig. :     Dust  over  umbilicus. 

Thromboplastin  has  been  recently  used  by  me  to  control  intestinal 
hemorrhage.  Twenty  cubic  centimeters  of  this  liquid  should  be  diluted 
with  8  ounces  of  water.  Excellent  results  were*  obtained  in  a  child  seven 
years  old  who  received,  by  mouth,  a  tablespoonful  of  this  dihition,  every 
half -hour.  Twelve  doses  in  all  were  given.  This  preparations  can  be  pro- 
cured from  the  Eesearch  Laboratory  of  the  New  York  City  Health 
Department. 

For  the  control  of  intestinal  hsemorrhage  astringent  injections  are 
not  to  be  relied  upon.  The  suprarenal  extract  is  a  very  good  haemostatic. 
I  have  frequently  used  very  small  doses  of  hydrastine  hydrochlorate,  ^/go 
to  ^/loo  grain,  three  times  a  day,  or  %  to  %  grain  suprarenal  extract, 
repeated  every  hour. 

The  injection  of  15  cubic  centimeters  to-  30  cubic  centimeters  of 
sterile  horse  serum  is  an  excellent  hsemostatic.  In  the  case  of  a  ''bleeder" 
recently  seen  by  me  in  the  Babies'  Wards  of  the  Sydenham  Hospital,  one 
injection  of  horse  serum  controlled  the  haemorrhage,  due  to  a  paracentesis, 
after  all  local  means  failed. 

If  bleeding  continues  in  spite  of  the  injection  of  horse  serum,  an  injec- 
tion of  15  to  30  cubic  centimeters  of  human  blood  serum  may  be  tried.  If 
the  latter  fails  we  should  resort  to  transfusion.  Transfusion  has  been 
recommended  by  Lambert  in  hsemorrhage  of  the  new-born. 


CHAPTER  V. 
INJURIES  OF  THE  NEW-BORN. 

Fracturks. 

Traumatism  during  labor  is  the  cause  of  most  fractures  in  the  new- 
born baby.  A  predisposition  may  exist,  due  to  defective  ossification.  When 
the  skeleton  is  no£  properly  developed,  then  a  separation  of  the  epiphyses  of 
the  long  bones  rather  than  an  actual  solution  of  continuity  of  the  diapheses 
occurs  (Ballantyne). 

This  author  also  doubts  the  osteomalacic  nature  of  fractures.  Ante- 
natal fragility  seems  to  exist  by  direct  heredity.  Griffith  reports  seventeen 
fractures  occurring  in  one  case^  during  the  first  two  years  of  an  infant's 
life.  Thus  we  can  see  that  there  must  be  some  other  factor  at  work  per- 
mitting recurring  fractures,  rather  than  invariably  traumatism. 

It  is  true  that  syphilis  has  frequently  been  given  as  a  possible  cause 
for  a  weak-boned  skeleton. 

Bfittle  bones  have  been  attributed  to  rickets.  Prenatal  disease  on  the 
part  of  the  infant  or  its  mother  is  frequently  the  cause  of  fracture.  Linck- 
describes  a  case  of  an  infant  that  was  born  in  little  more  than  one  pain. 
In  this  case  there  was  found  over  thirty  fractures  in  the  limbs  and  ribs. 

Most  of  the  fractures  seen  are  of  the  "green-stick"  variety.  The  prog- 
nosis in  these  cases  is  usually  good,  unless  some  complication  appears. 

The  following  case  was  seen  by  me  in  consultation  with  Dr,  A,  S. 
Bienenstock,  of  New  York: — 

An  infant  two  days  old  had  a  fracture  of  the  humerus.  Tlie  seat  of  the 
fracture  was  in  the  center  of  the  bone,  and  not  near  the  epiphysis. 

Mother's  History. — The  mother  of  the  infant  suffered  with  diabetes  for  the 
previous  eight  years,  having  between  4  and  4.5  per  cent,  of  sugar.  During  the 
latter  months  of  pregnancy  she  was  in  a  subnormal  condition.  The  labor  was 
dry,  and  quite  some  skill  was  required  to  deliver  the  infant.  The  mother  had  no 
breast-milk,  so  artificial, feeding  was  resorted  to. 

As  this  was  in  midsummer  the  infant  soon  became  dj'speptic  and  later 
developed  entero-colitis.  At  the  seat  of  the  fracture  callus  could  be  felt  several 
days  after  I  first  saw  this  infant.     Death  resulted  from  summer  complaint. 

Obstetrical  Paralysis  (Erb's  Paralysis  or  Birth  Palsy). 

This  condition  may  be  seen  soon  after  birth,  or  it  may  not  be  noticed 
for  several  days  after  that  event.     It  is  a  peripheral  paralysis  and  usually 

^American  Journal  of  the  Medical  Sciences,  Chap.  CXIII,  p.  426,  1897. 
*Arch.  of  Gynaek.,  x.\x,  264,  1887. 

(43) 


44  INJURIES  OF  THE  NEW-BORN. 

involves  the  deltoid,  biceps,  brachialis  anticus,  supraspinatus,  infraspinatus, 
and  supinator  longus  muscles.  It  may  also  involve  the  extensor  muscles  of 
the  wrist. 

Symptoms. — The  arm  hangs  limp  at  the  side  of  the  body.  The  position 
is  governed  by  gravitation.  The  forearm  is  extended  and  pronated,  and  the 
wrist  and  fingers  flexed.  Movement  does  not  cause  pain.  The  reaction  of 
degeneration  can  be  demonstrated  when  the  paralyzed  muscles  are  exam- 
ined with  the  electric  current.  Such  examinations  are  very  difficult  in  in- 
fants having  a  thick  layer  of  fat.  At  times  very  powerful  currents  are 
necessary,  thus  provoking  pain.  In  making  an  electrical  test,  the  normal 
arm  should  always  be  compared  with  the  affected  arm. 

Erb  demonstrated  the  fact  that  "it  is  possible  by  a  careful  examina- 
tion to  find  a  spot  two  centimeters  above  the  clavicle,  back  of  the  outer  edge 
of  the  sternomastoid  muscle,  corresponding  to  the  point  of  emergence  of 
the  sixth  cervical  nerve  between  the  scaleni,  at  which  point  irritation  by 
the  faradic  current  will  produce  a  contraction  in  the  deltoid,  biceps, 
brachialis  anticus,  and  supinator  longus  muscles;  and  if  the  irritation  be 
increased,  the  extensors  of  the  wrist  will  also  contract.  Pressure  upon  this 
particular  region  is  often  made  during  delivery,  either  by  the  clavicle,  or 
by  forceps,  or  by  the  fingers  of  the  obstetrician.  This  is  more  common 
when  there  is  a  breech  presentation  and  the  after-coming  head  is  extracted 
in  the  common  method.  The  index  and  middle  fingers  of  the  left  hand 
being  open  like  a  fork  over  the  shoulders  of  the  child,  traction  is  commonly 
made  upon  the  shoulders,  and  the  pressure  of  the  obstetrician's  finger  in  the 
neck  often  produces  injury  of  the  plexus.  In  some  cases  injury  of  the 
plexus  is  produced  by  attempts  to  bring  down  the  hand  or  arm  in  breech 
presentations,  or  to  replace  these  when  the  head  presents.  Forceps  appli- 
cations in  an  awkward  position  may  also  produce  this  injury." 

Progpiosis. — This  depends  on  the  time  when  the  treatment  is  com- 
menced. As  a  rule  paralysis  of  the  upper-arm  type  remains  three  or  four 
years.  In  a  case  of  mine  seen  recently  the  paralysis  remained  until  the 
child  was  5  years  old.  When  the  faradic  current  is  applied  and  the  muscles 
respond,  then  the  prognosis  is  good;  if  there  is  no  response,  a  cautious 
prognosis  should  be  given. 

Treatment. — The  arm  should  be  supported  with  a  sling.  Massage  aided 
by  a  faradic  current  is  sometimes  beneficial.  In  severe  cases  it  is  better  to 
use  the  galvanic  current,  using  the  mildest  current  that  will  produce  con- 
traction of  the  muscles.  If  the  child  is  old  enough  to  be  instructed,  gym- 
nastics should  be  tried  at  home  daily.  Strychnine  may  be  given  three  times 
a  day. 


CHAPTER  VI. 
ASPHYXIA  NEONATORUM   (APPARENT  DEATH  OF  THE  NEW-BORN). 

The  center  and  regulator  of  tlie  respiratory  movements  is  located  in 
the  medulla  oblongata  From  it  ako  is  sent  the  motor  impulse  which  gives 
rise  to  the  fir.  t  act  of  respiration. 

The  activity  of  this  center  is  believed  to  be  augmented  b}'  the  condition 
of  the  venosity  of  the  blood;  therefore,  all  interruptions  to  placental  re?pira- 
tion — for  instance  the  premature  detachment  of  that  organ  or  the  com- 
pression of  the  cord — and  all  obstacles  to  the  introduction  of  air  into  the 
trachea,  such  as  mucus  or  blood,  will  be  attended  with  violent  motor  im- 
pulses: first,  efforts  to  breathe,  and  later,  convulsive  movements  producing 
death  (Boisliniere). 

There  are  two  forms  of  this  condition  usually  observed :  first,  the 
apoplectic  form  called  by  older  Avriters  livida,  and  second,  the  antemic  form 
called  by  older  writers  pallida.  In  the  apoplectic  form  there  is  a  bluish 
discoloration  of  the  skin,  a  prominence  and  injection  of  the  conjunctivae, 
and  a  swollen  state  of  the  face  and  lips.  The  cardiac  pulsations  are  gener- 
ally strong,  and  the  cord  is  distended  with  blood.  In  the  anaemic  form  the 
child  has  a  degfdly  pallor;  the  lips  and  fingers  are  pale,  the  body  limp,  and 
muscles  relaxed.  .The  heart's  action  is  inaudible,  presenting  the  condition 
known  as  asystole.  Duvergie,  in  studying  the  asphyxia  of  adults,  noted  that 
when  people  were  removed  shortly  after  an  embankment  of  earth  had  buried 
them,  they  presented  a  turgescence  of  the  face,  a  violent  hue  of  the  skin,  and 
frequent  and  regular  pulsations  of  the  heart. 

When  they  were  found  some  time  after  an  embankment  of  earth  had 
buried  them,  they  presented  a  deathly  pallor  of  the  skin,  and  the  heart  sounds 
were  usually  inaudible  or  very  feeble.  Thus  it  is  apparent  that  the  above 
conditions  of  asphyxia  present,  first,  a  mild;  and  then  a  severe  type. 

Causes. 

The  main  causes  of  asphyxia  are  due  to: — 

1.  Compression  of  the  cord  in  a  natural  way. 

2.  Premature  detachment  of  the  placenta. 

3.  Forced  rotation  of  the  head  in  difficult  forceps  application  or  great 
contraction  of  the  uterus  in  head-last  cases,  thus  rendering  the  vessels  of 
the  uterus  impermeable  to  blood  and  suspending  the  placental  respiration. 
Another  cause  of  asphyxia  is  shortness  of  the  cord  from  its  encircling  the 
neck  tightly  after  the  head  is  born.    The  child's  face  in  this  condition  be- 

(45) 


46  DISEASES  OF  THE  NEW-BORN. 

comes  turgid  and  blue,  and  unless  relieved  the  child  will  die.  The  promptest 
treatment  consists  in  cutting  the  cord  above  the  child's  head  and  delivering 
the  infant's  body  as  quickly  as  possible.  Boisliniere  advises  the  above 
method  even  at  the  risk  of  fracturing  a  humerus. 

Sign  for  Distinguishing  the  Stillborn  from  the  Dead. 

Bedford  Blown  says  that,  the  best  means  for  distinguishing  the  still- 
born from  the  dead  is  to  be  found  in  the  temperature.  If  the  temperature 
keeps  near  the  normal,  we  must  not  cease  our  efforts  at  resuscitation,  even 
if  the  complete  suspension  of  cardia,c  and  respiratory  action  has  lasted  for 
twenty  minutes  or  more ;  but  if  the  temperature  of  the  child  suddenly  falls 
10,  15,  or  20  degrees  below  the  normal,  then  the  case  is  hopeless.  Another 
sign  is  the,  state  of  the  pupil :  in  the  dead  the  pupil  is  widely  dilated,  in  the 
stillborn  it  is  but  little,  if  at  all,  relaxed  (Therap.  Gaz.,  Vol.  XXXI, 
No.  6).  The  method  consists  in  injecting  into  each  arm  5  drops  of  whisky 
with  1  drop  of  tincture  of  belladonna.  If  the  infant  is  only  stillborn, 
the  nervous  and  circulatory  system  respond  quickly.  If  there  is  no  response 
or  only  a  very  feeble  one,  warm  sterilized  water  is  injected  under  the  skin 
(a  drachm  or  two)  and  also  about  2  drachms  with  a  drop  of  aromatic 
spirits  of  ammonia,  into  the  intestines.  After  this  dry  heat  is  applied.  If 
these  measures  fail  to  produce  a  reaction,  it  is  a  fair  test  of  the  absence  of 
vitality. 

Treatment. — If  the  child  presents  a  livid  condition  and  is  apparently 
apoplectic  with  the  cord  pulsating  strongly,  then  cut  the  cord  as  soon  as 
possible  and  allow  at  least  an  ounce  of  blood  to  escape.  Sometimes  it  is 
necessary  to  cut  the  cord  in  several  places.  If  bleeding  does  not  ensue  rap- 
idly, then  the  cord  should  be  severed  and  placed  in  warm  water  at  a  tem- 
perature of  105°  to  110°  F.    This  will  usually  stimulate  the  flow  of  blood. 

When  the  child  is  born  in  a  pallid  condition  and  feels  cold,  then  the 
cord  should  not  he  cut  until  all  pulsations  therein  have  ceased.  It  is  in  this 
condition  that  it  will  be  so  important  to  rapidly  cleanse  the  mouth,  nose, 
and  larynx  of  mucus  and  blood.  Some  authors  advise  mouth-to-mouth  suc- 
tion or  suction  made  through  a  soft-rubber  catheter  placed  in  the  larynx, 
but  these  are  usually  preliminary  means,  and  success  will  only  follow  me- 
thodical application  of  artificial  respiration. 

Byrd's  method  is  very  simple.  It  can  be  conducted  without  rough 
handling,  a  matter  of  vital  importance.  The  child's  body  rests  on  its  back 
and  is  supported  on  the  palm  surfaces  of  the  physician's  hands.  The  physi- 
cian, by  elevating  and  lowering  his  hands,  can  produce  inspiration  and 
expiration  in  a  rapid  and  efficient  manner.  This  method  is  well  worth 
trying.  An  important  point  to  remember  is  to  pull  the  tongue  forward; 
for  this  purpose  an  artery  clamp  will  serve  in  an  emergency,  if  the  physician 
does  not  have  Laborde's  forceps  for  traction  on  the  tongue. 


PLATE  JII 


The  Byid-Dew  IMethod  of  Artificial  Respiration.     A.   Extension.     B.   Semi- 
tlexion.     C,  Complete  flexion.      (C4randin  &  Jarman.) 


ASPHYXIA  NEONATORUM. 


47 


Labor de  advises  rhythmical  traciion  upon  the  tongue-  eight  or  ten  times 
a  minute.  This  is  a  valuable  method  and  can  be  used  while  the  child  is 
immersed  in  hot  water.  Thus,  the  benefit  of  the  stimulus  on  the  tongue  will 
be  apparent  while  the  hot  bath  is  used. 

Hypodermics  of  strychnine,  Vioo  grain,  combined  with  5  or  10 
minims  of  whisky,  may  be  indicated.  Flushing  the  colon  with  a  pint  or 
more  of  water,  temperature  110°  or  115°  F.,  to  which  a  half-drachm  of 
alcohol  has  been  added,  may  also  aid  in  stimulating  the  circulatory  and  the 
respiratory  tract.  It  is  advisable  to  persevere  for  some  time  with  the 
above  method  of  resuscitation,  even  though  we  may  be  successful.  It  fre- 
quently happens  that  new-born  infants  will  respond  to  active  treatment  and 
show  signs  of  life,  but  we  must  continue  for  some  time,  or  the  respirations 
will  cease  and  the  infant  may  die. 


Fig.  15. — Ribemont's  Tube  for  Inflating  the  Lungs. 

A  valuable  means  of  restoring  suspended  animation  consists  in  im- 
mersing the  new-born  infant,  first,  into  very  warm  water,  and  then  into  cold 
water.    Alternate  from  hot  to  cold  water  every  ten  or  fifteen  seconds. 


Inflation  of  the  Lungs. 

This  method  is  sometimes  useful  when  other  means  fail.  Some  authors 
advise  the  mouth-to-mouth  method.  This  consists  in  filling  the  cheeks  with 
fresh  air  and  then  blowing  the  same  into  the  infant's  mouth.  It  can  also 
be  done  by  introducing  a  catheter  into  the  infant's  larynx.  While  the  mouth- 
to-mouth  method  is  simpler,  it  is  not  always  a  sure  way  of  inflating  the 
lungs.  Quite  frequently  the  air  will  be  blown  from  the  mouth,  through  the 
pharynx,  into  the  stomach.  To  avoid  the  latter,  the  head  should  be  thrown 
backward,  and  compression  made  over  the  epigastrium.  If  the  nose  is  closed, 
air  is  less  likely  to  enter  the  stomach. 

M'outh-to-mouth  insufflation  of  air  is  not  devoid  of  danger.  Reich 
reported  a  case  of  tuberculous  meningitis  due  to  attempts  at  reanimation 
by  a  tuberculous  midwife.    The  Ribemont  laryngeal  tube  is  much  safer. 


48 


DISEASES  OF  THE  NEW-BORN. 


Eibemont's  tube  for  inflating  the  lungs  is  inserted  like  an  intubation 
tube.    It  serves  two  purposes : — 

1.  Forcing  air  into  the  lungs. 

2.  The  aspiration  of  mucus  from  the  trachea  or  bronchi. 

Great  care  should  be  used  with  any  and  all  methods.     No  force  is 
necessary. 


INFANT  PULMOTOR 


Fig.  16. — Infant  Pulmotor. 


Literature  records  many  successful  cases  of  resuscitation  of  the  asphyxi- 
ated child  with  the  aid  of  the  Draeger  pulmotor. ^ 

The  infant  pulmotor  weighs  twenty  poimds  and  is  carried  in  a  box 
about  19  inches  by  10  by  5.  It  contains  a  cylinder  of  oxygen.  Each  cylin- 
der contains  oxygen  sufficient  for  the  continuous  working  of  the  apparatus 
for  one  hour  (Fig.  16). 

Two  flexible  metal  tubes  connect  the  instrument  with  the  mask:    one 


H.  D.  Fry,  Surgery,  Grynecology,  and  Obstetrics,  Oct.,  1913. 


ASPHYXIA  NEONATORUM.  49 

forces  the  oxygen  into  the  lungs  under  the  required  pressure ;  the  other  is  for 
suction,  and  removes  the  vitiated  air  from  the  organ. 

Technique. — The  mouth,  throtit,  and  upper  air  passages  are  freed  of 
mucus  by  gauze  wrapped  round  the  finger  and  by  holding  the  infant  head 
downvi^ard.  It  is  then  placed  in  the  dorsal  position  upon  a  table  or  hard 
surface,  shoulders  raised  and  head  extended.  If  relaxed,  the  lower  jaw  must 
be  held  up  and  pushed  forward.  The  tongue  is  pulled  well  out  with  a  silk 
thread  passed  through  the  tip.  This  is  preferable  to  the  forceps  or  tenacu- 
lum, as  it  does  not  interfere  with  the  close  application  of  the  mask.  The 
mask  is  tightly  applied  to  the  face,  covering  the  mouth  and  nose,  and  held 
firmly  by  an  assistant  or  by  a  rubber  band  encircling  the  head.  The  trachea 
is  pressed  gently  against  the  spine  so  as  to  close  the  oesophagus,  and  if  this 
is  not  enough  to  prevent  distention  of  the  stomach  a  small  gauze  sponge, 
attached  to  a  string,  can  be  placed  in  the  oesophagus  below  the  larynx. 
Inspiratory  and  expiratory  movements  are  induced  by  moving  the  lever 
alternately  from  side  to  side,  filling  the  lungs  and  expanding  the  chest 
walls,  holding  the  inflation  for  a  few  moments,  and  then  deflating  the  lungs. 
If  the  infant  should  make  any  voluntary  effort  to  breathe,  the  manipulation 
of  the  apparatus  should  be  so  timed  as  to  inflate  during  the  inspiratory 
efforts  and  deflate  during  the  expiratory.  Efforts  to  resuscitate  the  infant 
should  not  be  abandoned  as  long  as  there  is  any  heart  action. 


CHAPTER  VII. 

FCETAL  ICHTHYOSIS. 

This  condition  is  described  by  Ballantyne,  Kyber,  Wassmuth,  and 
Carbone  as  a  skin  disease  of  the  foetus  most  probably  developed  about  the 
fourth  month  of  intrauterine  life.  It  consists  of  horny  epidermic  plates 
over  the  whole  surface  of  the  body,  separated  •  from  each  other  by  fissures 
and  furrows,  associated  with  certain  deformities  of  the  mouth,  nose,  eyes, 
ears,  and  extremities,  and  leading  to  the  death  of  the  infant  very  soon  after 
birth. 

It  is  a  rare  condition,  as  only  43  cases  could  be  found  in  the  whole 
literature  up  to  the  year  1895.  For  the  following  case  I  am  indebted  to 
Dr.  A.  S.  Daniel  :— 

Clinical  History. — This  case  was  first  seen  five  hours  after  birth.  The  child 
had  passed  urine  and  meconium,  cried  continuously,  sleep  was  impossible.  The 
slightest  jar  of  the  crib  or  exposure  to  the  air  increased  the  crying.  The  respiration 
was  irregular,  the  surface  of  the  body  cold.  The  child  swallowed  with  difficulty 
and  was  fed  with  the  aid  of  a  medicine  dropper.  The  child  died  suddenly  twenty- 
four  hours  after  birth.     The  temperature  taken  soon  after  birth  was  103°  F. 

Description  of  the  Child. — There  was  no  resemblance  between  the  child  and  a 
human  being  or  any  living  thing.  The  tongue  was  the  only  part  of  the  body  that 
seemed  capable  of  motion.  The  body  presents  the  appearance  of  having  been  in  an 
integument  much  too  small  for  the  skeleton,  and  Nature  in  its  growth  had  so 
stretched  the  skin  that  it  has  the  appearance  of  being  torn  in  some  places.  Where 
it  is  torn  through,  a  piirple-covered  slit  appears;  where  torn  partly  through,  a 
yellowish-colored  fissure  remains.  There  is  no  uniformity  of  arrangement  of  the 
fissures.  Fewer  are  found  on  the  back,  and  those  on  the  extremities  are  more 
shallow.  The  color  of  the  fissure,  a  purplish  red,  is  in  marked  contrast  to  the  color 
of  the  skin.  In  a  few  places  bright  blood  is  found,  as  if  the  break  were  of  recent 
origin.  The  whole  body  is  cold  and  rigid.  The  scalp  is  divided  into  fissures  and 
numerous  irregular  conical  projections,  varying  in  size.  A  few  thin  hairs  are 
found  on  the  lateral  surface  of  the  scalp.  The  external  ears  are  replaced  by  conical 
projections.  The  palpebral  fissures  are  filled  with  purplish-red  masses;  deep  down 
in  the  sockets,  eyeballs  can  be  distinguished.  The  nose  is  fiattened  and  is  identified 
by  the  widely  opened  nostrils.  The  mouth  is  open,  showing  a  non-hypertrophied 
tongue.  The  lips  are  of  a  purplish-red  color.  The  mouth  measures  5  centimeters 
in  length.  Circumference  of  head,  36.5  centimeters;  glabella  to  occiput,  18.5 
centimeters;  ear  to  ear,  15.5  centimeters.  The  neclc  is  short.  Anteriorly  a 
fissure  extends  from  the  neck  to  the  umbilicus,  2  centimeters  in  width.  From  this 
fissure,  ridges  of  yellow  skin  and  purple  fissures  extend  toward  the  axillae;  they 
are  of  irregular  size  and  depth. 

The  extremities  are  rigid  and  in  the  foetal  position.  The  arms  can  be  raised 
only  at  right  angles  with  the  body.     They  cannot  be  extended  at  the  elbow.     The 

(50) 


FCETAL  ICHTHYOSIS.  51 

hands  are  thickened  and  the  fingers  are   rudimentary.     Tlie   legs  are  crossed.     The 
motion  at  the  hip  and  knee  joint  is  very  imperfect.     The  toes  are  rudimentary. 

The  median  raphe  in  the  scrotum  is  faintly  marked;  testicles  are  not 
descended.  The  penis  is  Yj  centimeter  in  length.  The  anus  is  open.  The  length 
of  the  fcetus  is  42  centimeters,  and  its  weiglit  is  4  pounds  13  ounpes.  In  this  case 
it  was  impossihle  to  find  any  clinical  cause  for  the  disease. 

Of  the  cause  of  foetal  ichthyosis  practically  nothing  is  known.  That 
it  is  not  a  fatal  disease  in  utero  is  demonstrated  hy  the  fact  that  only  one 
case  thus  far  has  been  stillborn. 


CHAPTEK  VIII. 

INFLAMMATORY  AND  NON-INFLAMMATORY  CONDITIONS. 

Icterus  ISTeonatorum. 

This  form  of  icterus  is  frequently  designated  as  a  physiological  con- 
dition. It  usually  begins  on  the  second  or  third  day  after  birth,  and  may 
continue  for  a  week  or  even  a  month.  Henoch  reports  a  case  of  icterus 
brought  to  his  clinic  which  lasted  five  weeks  and  ended  fatally.  The  ma- 
jority of  text-books  describe  this  condition  as  a  mild  disease  and  give  a  good 
prognosis.  There  are  many  theories  as  to  the  causes  leading  up  to  this 
condition.  The  hasmatogenic  theory  maintains  that  a  disintegration  of  red 
corpuscles  takes  place.  This  liberates  the  hgemogiobin,  giving  rise  to  the 
yellowish  pigmentation. 

Eacchi,  of  Naples,  disproved  the  correctness  of  this  theory  by  a  series 
of  blood-counts  which  he  reported  at  the  International  Medical  Congress 
held  at  Eome  in  1895. 

"We  can  scarcely  believe  that  the  red  corpuscles  simply  go  to  pieces  in 
the  blood,  and  that  the  products  of  such  disintegration,  floating  freely  about 
or  temporarily  lodged  in  the  tissues,  give  rise  to  the  yellow  color.  It  is  far 
more  in  accordance  with  the  workings  of  the  living  organism  to  suppose 
that  the  disintegration  takes  place  in  some  organ,  e.g.,  liver  or  spleen,  and 
if  the  products  thereof  are  floating  about,  it  is  after  passing  such  organ 
and  on  their  way  to  final  elimination." 

Infant  F.  J.  was  seen  by  me  when  three  days  old.  Had  greenish  stools  con- 
taining mucus,  and  appeared  colicky  and  cried  considerably.  No  vomiting.  There 
was  a  universal  yellowish  pigment  of  the  body;  jaundice  well  marked;  gums  were 
yellowish;  conjunctival  mucous  membrane  showed  yellowish  pigmentation.  The 
umbilicus  was  somewhat  excoriated  and  moist  from  the  presence  of  pus.  The 
diagnosis  made  was  septic  omphalitis,  resulting  in  hematogenic  jaundice.  Very 
small  doses  of  calomel,  140  g'"^'"?  several  times  a  day,  were  ordered;  also  colon 
irrigations  with  chamomile  tea.  The  infant  was  nursed  by  its  mother.  Aseptic 
treatment  of  the  umbilicus  with  sterile  gauze,  cleansing  with  bichloride,  and  then 
dusting  the  parts  with  talcum  salicylicuui  quickly  henled  the  inllammatory  con- 
dition. The  infant  recovered  in  about  one  week,  showing  no  sign  of  its  previous 
jaundice. 

The  following  case  is  noteworthy  owing  to  its  rarity; — 

An  infant  was  born  of  apparently  healthy  parents.  Dr.  Mehrenlander,  the 
physician  in  attendance,  stated  that  there  was  nothing,  abnormal  at  the  time  of 
birth.  The  infant  weighed  about  seven  jjounds.  It  was  the  fourth  child.  Three 
children  of  this  same  family  had  previously  died  on  the  third  day  after  birth.     They 

(52) 


SCLEREMA  NEONATORUM.  53 

were  to  all  appearances  healthy,  but  were  jaundiced.  Nothing  was  noticeable  with 
them,  excepting  the  yellow  pigmentation  of  the  skin.  The  child  died  before  I  ar- 
rived at  tlie  bedside.  It  was  three  days  old.  The  skin  then  presented  a  deep  yellow- 
ish-green pigmentation,  more  marked  on  the  abdomen.  The  conjunctival  mucous 
membrane  was  deeply  pigmented.  There  was  no  inflammatory  condition  noticeable 
in  tlie  region  of  tiie  umbilicus.  The  cord  was  dressed  witli  aseptic  gauze,  and  no 
infection  was  suspected  from  this  channel.  The  attending  physician  suspected 
sypliilis  in  the  father.  There  were  no"  other  symptoms.  Neither  vomiting  nor 
diarrhea.     A  stool  passed  before  the  infant  died,  which  looked  like  meconium. 

An  interesting  jwint  about  the  ease  is  that  this  was  the  fourth  child  in  that 
family  which  died  of  icterus  neonatorum  a  few  days  after  birth.  The  child  died 
witliout  any  apparent  suffering,  showing  no  symptoms  of  illness.  The  temperature 
when  taken  was  normal. 

Zweifel  describes  a  series  of  cases  of  icterus  resulting  from  the  effects 
of  chloroform  passing  through  the  placenta.  The  writer  has  noted  the  asso- 
ciation of  icterus  neonatorum  in  a  large  number  of  children  born  after  a 
severe  labor,  requiring  prolonged  chloroform  narcosis.  This  may  have  been. 
accidental,  yet  it  is  ivorth  noting. 

James  D.  Voorhees,  in  responding  to  my  question  concerning  the  asso- 
ciation of  chloroform  anaesthesia  and  icterus  at  the  Sloane  Maternity  Hos- 
pital, states  that  "all  women  receive  chloroform  at  said  hospital,  and  about 
33  per  cent,  of  the  infants  born  are  jaundiced.  All  premature  infants 
also  are  jaundiced." 

Sclerema  Neonatorum. 

This  disease  is  characterized  by  a  hardening  or  thickening  of  the  skin 
and  the  subcutaneous  cellular  tissue.  The  pathological  lesions  have  been 
carefully  studied  by  Xorthrup.  His  case  was  a  foundling  born  amid  insani- 
tary surroundings.  When  five  days  old  the  legs  were  swollen  and  the  feet 
as  hard  as  a  board. 

The  swelling  spread  upward,  involving  every  part  of  the  body.  The 
temperature  in  the  rectum  was  35°  C.  (95°  F.).  The  infant  died  on  the 
ninth  day.  The  body  felt  as  though  it  were  frozen.  Osier  also  describes 
this  condition  in  this  country. 

Symptoms. — An  oedema-like  swelling,  very  cold  to  the  touch,  and  very 
hard  on  palpation,  involving  circumscribed  areas,  appears  soon  after  birth. 
I  have  seen  sclerema  spread  from  the  shoulders  to  .the  trunk  and  arms. 

The  infant  appears  very  sick.  The  temperature  is  subnormal,  and 
recovery  is  rare. 

Was  called  to  see  an  infant  five  days  old.  Found  the  trunk  swollen,  the  hands 
and  feet  cold,  and  the  temperature  in  rectum  subnormal.  The  infant  refused  the 
breast  and  had  no  strengtli.  Brandy  and  water  were  prescribed.  ]\Iustard  foot-bath 
ordered,  and  one  pint  of  warm  saline  solution"  injected  into  the  colon.  Tliere  was  no 
nausea  or  vomiting.  No  retention  of  urine.  Sclerema  neonatorum  was  diagnosed. 
The  swelling  spread,  involving  tlie  legs  and  arms,  until  the  whole  body,  including  the 


54  INFLAMMATORY  AND  NON-INFLAMMATORY  CONDITIONS. 

face,  was  puffed  and  hard.     The  infant  could  no  longer  open  its  eyes  and  died  on 
the  ninth  day  in  convulsions. 

Mastitis  Neonatorum. 

The  new-born  infant  frequently  secretes  a  fluid  in  the  mammae.  Fe- 
males, both  human  and  animal,  occasionally  secrete  milk  without  having 
been  previously  pregnant.  With  regard  to  the  milk  secreted  by  infants, 
there  is  some  doubt  about  its  real  nature.  Kollicker  does  not  view  it  as  a 
true  milk,  but  considers  its  appearance  connected  with  the  formation  of 
the  mammary  glands.    This  secretion  is  also  known  as  witch's  milk. 

Sinety,  on  the  other  hand,  upon  anatomical  grounds,  considers  it  a 
true  lacteal  secretion.  It  probably  is  a  sort  of  imperfect  milk,  loaded  with 
leucocytes,  and  this  is  the  more  likely  as  Vollard^  notices  that  it  frequently 
ends  in  abscess. 

Schlossberger  gives  an  imperfect  quantitative  analysis  of  a  sample  of 
milk  obtained  by  squeezing  the  breasts  of  a  new-bom  infant,  a  male.  In 
the  course  of  a  few  days  about  a  drachm  was  obtained.  The  following  was 
the  result  of  the  analysis : — 

Water 96.75 

Fat  0.82 

Ash  0.05 

Casein,  sugar,  and  extractives 2.83 

Sugar-reaction strong 

The  most  complete  analysis  we  possess  of  such  milk  is  by  von  Gesner : — 

Milk-fat 1.456 

Casein 0.557 

Albumin   0.490 

Milk-sugar 0.956 

Ash 0.826 

Water    95.705 

Total  solids 4.295 

I  was  called  to  see  a  female  infant  six  days  old.  The  mother  told  me  that  the 
breasts  were  swollen  and  contained  milk.  The  same  could  be  expressed  by  gentle 
stroking  of  the  mammse.  The  treatment  consisted  of  the  application  of  an  ice-bag 
and  inunctions  of: — 

IJ,  Ung.  ext.  belladonna   2  drachms 

Ung.  hydrarg.  cin 1  drachm 

Cold  cream 1  ounce 

M.     Apply  on  linen  with  tight  compresses. 

After  several  days  the  breast  dried  and  the  swelling  disappeared. 
Another  infant,  three  weeks  old,  was  seen  by  me  recently,  in  consultation.    The 
mother  was  delivered  by  a  midwife,  and  her  condition  as  well  as  that  of  the  infant 

*  "Traits  des  Maladies  des  Enfants  Nouveau-nfis,"  third  edition,  1837,  p.  717. 


PERITONITIS  IN  THE  NEW-BORN.  55 

was  apparently  normal.  The  infant's  breasts,  when  seven  days  old,  appeared  tender 
and  swollen,  and  the  mother  was  advised  to  poultice  them  with  flaxseed.  This  she 
did,  and  in  addition  squeezed  the  secretion  from  the  infant's  breasts.  Tliis  trauma- 
tism caused  irritation,  inflammation,  and  finally  the  formation  of  an.  abscess.  An 
incision  was  made,  the  pus  evacuated,  and  the  wound  healed. 

It  is  important  to  remember  that  the  lacteal  secretion  in  an  infant's 
breast  is  a  physiological  condition,  and  if  undisturbed  will  be  absorbed 
gradually. 

Erysipelas  in  the  New-born. 

When  this  disease  occurs  in  the  new-bom,  and  the  mother  has  a  septic 
peritonitis  or  other  infectious  disease,  the  infant  should  be  immediately 
isolated  from  the  mother.  The  symptoms  are  the  same  as  those  seen  in 
erysipelas  of  older  children,  although  vomiting  and  symptoms  of  general 
sepsis  most  often  accompany  this  condition.    The  fontanel  is  depressed. 

Prognosis. — The  prognosis  is  usually  very  grave,  especially  so  if  the 
infant  must  be  removed  from  its  mother's  breast. 

Treatment. — The  strictest  antisepsis  must  be  used.  An  infant  should 
be  placed  under  the  care  of  a  trained  nurse,  and  all  instructions  in  regard 
to  the  hygiene  of  the  infant  must  be  strictly  carried  out.  The  general  plan 
of  treatment  is  the  same  as  that  outlined  in  the  chapter  on  "Erysipelas." 

Tuberculosis  in  the  Nev^-born. 

The  transmission  of  tuberculosis  from  the  mother  to  the  new-bom 
is  extremely  rare.  Cases  are  on  record  in  which  the  tubercle  bacilli  were 
transmitted  from  the  mother  to  the  infant.  An  occasional  transmission  of 
tuberculosis  takes  place  through  the  placenta.  The  reason  for  the  infre- 
quency  of  this  occurrence  is  that  the  blood  of  a  tuberculous  patient  rarely 
contains  tubercle  bacilli.  Schmorl  and  Birch-Hirschfeld  believe  that  ma- 
ternal tuberculosis  can  be  transmitted,  but  not  before  the  end  of  the  fifth 
month  of  pregnancy,  and  that  the  placenta  is  always  tuberculous  when  the 
foetus  is  infected.    (For  further  details  see  chapter  on  "Tuberculosis.'^) 

Peritonitis  in  the  New-born. 

Under  "Septic  Omphalitis"  I  have  described  a  case  of  septic  infec- 
tion seen  in  consultation  practice.  The  case  recovered.  At  times  the  in- 
flammatory condition  will  extend  from  the  umbilicus  to  the  peritoneum,  and 
thus  a  septic  peritonitis  results. 

Bacteriology. — In  such  pyogenic  infections  the  streptococcus  can  be 
found.     The  bacteria  gain  entrance  directly  through  the  umbilical  vessels. 

Pathology. — The  same  lesions  affecting  the  serous  membrane,  as  the 
pleura  and  the  pericardium,  are  found  in  the  peritoneum.  Adhesions  fre- 
quently remain. 


56  INFLAMMATORY  AND  NON-INFLAMMATORY  CONDITIONS. 

The  symptoms,  prognosis,  and  treatment  are  described  in  the  article 
on  "Acute  Peritonitis/'  Part  V. 

Pemphigus  Neon-atorum.^ 

This  condition  is  seen  occasionally  in  the  new-born  infant.  It  consists 
of  blebs,  which  contain  yellow  sermn.  In  size  they  vary  from  that  of  a  pea 
to  that  of  a  small  bean.  When  these  rupture  they  are  replaced  by  superficial 
ulcers  covered  with  a  thin,  black  crust.  Sometimes  a  violet  stain  is  left, 
which  may  last  for  some  time.  The  duration  of  each  bulla  is  about  one  week. 
The  location  of  the  eruption  is  on  the  palms  of  the  hands  and  the  soles  of 
the  feet.  It  is  a  streptococcus  infection.  The  cases  seen  by  me  have  in- 
variably occurred  in  poorly  nourished  children  such  as  we  find  in  athrepsia 
(marasmus). 


'  See  article  on  "Chronic  Pemphigus." 


CHAPTER  IX. 
ABNORMALITIES  AND  CONGENITAL  MALFORMATIONS. 

Angeioma. 

Circumscribed  dilatations  of  the  blood-vessels  or  capillaries  are  occa- 
sionally seen  in  the  new-born  baby.  Spongy  tumors  consisting  of  tortuous 
blood-vessels  of  a  bluish-red  color  are  usually  seen.    These  tumors  are  filled 


Fig.  17. — Infant  ten  months  old.  From  my  children's  service  at  the 
German  Poliklinik.  The  mass  of  bluish,  tortuous  vessels  interfered  with 
the  eyesight.  Bleeding  was  very  easily  provoked.  Surgical  treatment  was 
the  only  means  of  eradicating  this  mass.     (Original.) 

with  blood  and  grow  very  rapidly.  In  a  case  seen  by  me  (see  Fig.  17)  the 
mass  was  adherent  to  the  forehead  and  completely  obliterated  the  sight  of 
the  left  eye.  This  condition  is  one  that  can  easily  be  remedied  by  prompt 
surgical  treatment.  Some  cases  will,  if  neglected,  ultimately  result  in 
sarcomatous  degeneration. 

Treatment. — Injections  into  the  mass  of  a  5  per  cent,  nitrate  of  silver 
solution,  or  destroying  the  mass  with  a  galvanocauter}^,  chromic  acid,  or 

(57) 


58  ABNORMALITIES  AND  CONGENITAL  MALFORMATIONS. 

nitric  acid,  are  most  generally  used.  A  good  plan  is  to  apply  first  pure 
carbolic  acid,  after  which  the  fuming  nitric  acid  should  be  used.  This 
latter  method  is  painless  and  effective. 

Harelip. 

This  congenital  deformity  is  frequently  seen  in  children.  Sometimes 
it  is  simply  "a  slight  indentation  in  the  lip,  or  the  fissure  may  extend  to 
the,. nostril."    The  treatment  is  surgical. 


V 


Fig.  18. — Harelip  Nipple.^ 


Cleft  Palate. 


This  abnormality  is  frequently  seen  in  children.  While  the  soft  palate 
only  may  be  affected,  it  not  infrequently  happens  that  the  fissure  extends 
through  the  hard  palate,  thus  causing  a  wide  gap  in  the  roof  of  the  mouth. 

Feeding  Children  with  Cleft  Palate. — An  infant  bom  with  cleft  palate 
has  a  greater  struggle  for  existence  than  a  child  born  without  this  deformity. 
It  is  advisable  to  give  the  best  possible  food,  and,  therefore,  breast-milk  only 
should  be  used.  The  milk  should  be  drawn  from  a  woman's  breast  by 
means  of  a  breast-pump,  as  described  in  the  section  on  "Specimen  of  Breast- 
milk  for  Chemical  Examination." 

An  artificial  nipple  should  be  attached  to  the  feeding-bottle,  and  to  the 
former  should  be  attached  a  flap  of  India  rubber  so  made  that  it  fits  the 
roof  of  the  mouth.  The  pressure  of  the  nipple  against  the  piece  of  rubber, 
when  in  position,  converts  it  into  an  artificial  palate-piece,  and  prevents 
the  escape  of  the  milk  into  the  nose  during  the  effort  of  swallowing.  This 
shield  is  chosen  to  avoid  permitting  curdled  milk  to  pass  into  the  recesses 
of  the  turbinated  bones  and  to  cause  aphthous  patches.     (See  Fig.  18.) 

It  is  advisable  to  operate  on  an  infant  for  this  deformity  between  the 
third  and  sixth  months  of  its  life,  if  sufficient  progress  in  its  development 
will  warrant  it. 

When  the  above  method  of  feeding  is  not  satisfactory  and  the  child 
shows  evidences  of  starvation,  then  we  must  resort  to  gavage.  (See  article 
on  '^Gavage.") 

Our  aim  should  be  to  build  up  the  infant  from  its  birth,  with  breast- 
milk  if  obtainable.    In  one  case  known  to  me  the  breast-milk  was  pumped 


*  This  harelip  nipple  can  be  procured  from  the  Miller  Rubber  Manufacturing  Co., 
Akron,  Ohio. 


CONGENITAL  ADENOIDS.  59 

off  every  four  hours  and  tlie  infant  was  nourislicd  by  gavago  with  this  milk. 
When  breast-milk  is  not  obtainable,  then  properly  modified  milk  should  be 
used,  to  conform  witb  the  age  and  requirements  of  the  child.  If  the  child 
does  not  assimihite  its  food  properly,  the  operation  should  be  postponed  until 
tile  child  is  built  up  and  strong  enough  to  stand  the  operation;  hence  the 
guide  for  estimating  the  time  for  the  operation  is  dependent  more  on  proper 
feeding  than  on  any  other  factor. 

Hygienic  measures  are  very  important,  as  the  irritation  by  food  will 
frecjuently  cause  inflammation  in  the  mouth.  For  details  of  the  surgical 
treatment  the  reader  is  referred  to  the  many  good  text-books  on  operative 
surgery. 

Tongue-tie   (Adii/Esia  Lingu.e). 

Tongue-tie  consists  of  an  abnormally  short  frsenum.  In  some  instances 
it  may  interfere  with  nursing,  and  possibly  with  speaking.  It  is  one  of  the 
most  trivial  disorders  of  infancy. 

Treatment. — Incise  the  frtenum  near  its  attachment  to  the  tongue  with 
a  pair  of  curved  scissors.  The  incision  may  be  enlarged  with  the  aid  of 
some  dull  instrument.  Some  authors  advise  using  the  finger-nail,  which 
latter,  however,  is  not  aseptic.  A  tongue-tie  should  not  be  operated  upon 
if  an  infection  exists  in  the  immediate  surroundings. 

The  after-treatment  consists  in  using  a  bland  mouth  wash,  such  as  a 
1  per  cent,  listerine  solution,  or  1  per  cent,  alum  solution,  especially  after 
feeding  the  child. 

Congenital  Adenoids. 

We  occasionally  meet  with  infants  in  which  this  condition  exists.  This 
mechanical  impediment  prevents  breathing  through  the  nose.  An  infant, 
therefore,  is  at  a  great  disadvantage,  because  it  cannot  breathe  while  nurs- 
ing.   The  following  case  will  serve  to  illustrate  this  condition : — 

I  was  called  to  see  an  infant,  Mary  W.,  in  consultation.  The  attending  physi- 
cian gave  me  the  following  history:  The  infant  is  twenty  days  old  and  weighs  6 
pounds  and  14  ounces.  At  birth  she  weighed  7  pounds.  She  was  nursed  at  the 
mother's  breast  for  about  one  week.  Tlie  infant  seemed  to  dislike  the  breast,  as  she 
would  draw  and  immediately  let  go  of  the  nipple.  The  mother  believed  the  infant  did 
not  like  the  taste  of  her  milk.  A  wet-nurse  was  procured,  and  the  same  trouble  was 
encovmtered  ;■  the  infant  would  take  one  swallow  and  then  let  go  of  the  nipple  in 
order  to  get  her  breath.  A  nipple-shield  was  then  used,  but  the  same  difficulty  was 
encountered.  The  family  believed  that  the  infant  did  not  like  breast-milk,  so  she 
was  given  bottle  feeding.  She  took  the  nipple  of  the  bottle,  drew  quite  well,  and 
then  let  go,  when  it  was  necessary  for  respiration.  I  ordered  spoon  feeding,  and  this 
worked  qjuite  well.  The  breast-milk  was  pumped  from  the  wet-nurse  and  fed  by 
spoon.  This  method  was  successful.  The  child  swallowed  a  spoonful  of  milk  and 
then  had  a  chance  to  breathe.  An  examination  of  the  rhino-pharynx  revealed 
adenoids.  These  were  removed  with  the  aid  of  a  sharp  spoon,  and  three  days  later 
normal  conditions  existed. 


60  ABXOR]VIALITIES  AND  CONGENITAL  MALFORMATIONS. 

The  infant  was  again  put  to  the  breast  when  six  weeks  old  and  continued  to 
nurse  successfully  for  six  months.  She  was  then  weaned,  owing  to  the  illness  of 
the  wet-nurse.  Cows"  milk  was  substituted.  The  child  is  today  a  perfectly  healthy 
little  girl. 

Peoteusion  of  the  Eabs. 

Protrusion  of  the  ears  is  frequently  seen  in  children.  The  anxious 
mother  will  consult  the  phj-sician  regarding  the  treatment.  These  cases  are 
easily  managed  in  very  young  infants.  A  fenestrated  cap,  closely  fitting  to 
the  head  so  that  the  ears  are  well  held  back  in  their  normal  position,  has 
served  me  very  well.  Young  infants  object  to  having  their  heads  covered, 
but  soon  liecome  accustomed  to  this  cap,  as  it  is  only  worn  at  night  and 
removed  in  the  morning.  It  is  advisable  to  change  the  cap  frequenth',  as 
some  children  perspire  from  its  use.  It  must  be  worn  for  months  before  any 
benefit  is  noted. 

In  very  severe  cases  in  which  the  above  treatment  is  not  successful,  it 
may  be  necessary  to  call  in  the  surgeon.  The  operation  is  a  simple  one  and 
the  result  is  excellent. 

Abnoemalities  of  the  Aie  Passages. 

When  there  is  deficient  oxygenation  of  the  lungs,  collapse  frequently 
occurs,  and  is  called  atelectasis  pulmonum.  This  condition  is  due  to  the 
unaerated  condition  of  the  vesicles.  The  trouble  is  usually  found  in  the 
nasophar}'nx  in  the  form  of  adenoids,  unless  some  rare  malignant  condition 
is  present. 

Many  pigeon-breasted  children — with  apparent  rachitic  manifestations 
of  the  thorax — owe  this  anatomical  peculiarity  more  to  improper  oxj'gena- 
tion  of  the  lungs  than  to  improper  feeding.  In  such  children  it  is  not  rare 
to  meet  with  congenital  adenoids.  (Eead  article  on  "Congenital  Ade- 
noids.") 

It  is  to  be  understood  that  changing  the  food  or  giving  restorative  treat- 
ment, such  as  iron  or  codliver-oil,  cannot  cure  such  a  child  until  the  cause 
is  eradicated. 

Congenital  Stenosis  of  the  Larynx. 

In  the  chapter  on  "Inherited  Syphilis"  I  describe  a  case  of  syphilitic 
stenosis  of  the  larynx  which  necessitated  a  tracheotomy.  Several  years  ago 
a  child  was  brought  'to  my  clinic  suffering  with  cyanosis  and  difficult  breath- 
ing. Intubation  was  tried  without  affording  any  relief.  As  a  last  resort 
tracheotomy  was  performed,  but  this  afforded  no  relief.  A  post-mortem 
examination  showed  that  we  were  dealing  with  a  diverticulum  of  the  trachea. 
In  addition  thereto  the  larynx  and  trachea  were  lined  with  a  series  of  syph- 
ilitic ulcerations. 


CEPHALHEMATOMA.  61 


Prominent  Sternum. 

This  is  frequently  ealled  pigeon-breast.  It  is  usually  seen  in  older 
C'liildron.  It  is  occasionally  seen  as  a  result  of  Pott's  disease,  but  more  fre- 
quently it  is  associated  with  rickets.  It  has  been  described  by  me  in  the 
chapter  on  "Eachitis." 

Depressed  Sternum. 

Congenital  depression  of  the  sternum  is  occasionally  seen  in  very  young 
infants.  It  is  more  frequently  seen  as  a  funnel-shaped  depression,  and  is  a 
symptom  of  structural  weakness.  It  more  often  accompanies  a  general 
rachitic  manifestation,  to  which  I  call  attention  in  the  chapter  on  "Kachitis." 


Hematoma  of  the  Sterno-mastoid. 

During  labor  traumatic  conditions  frequently  induce  haemorrhages. 
These  conditions  are,  therefore,  seen  in  natural  labor  with  very  large  chil- 
dren, or  when  forceps  are  used.  Pressure  is  cited  by  most  authors  as  one  of 
the  causes  of  this  condition.  Henoch  believes  that  hsematoma  of  the  sterno- 
mastoid  is  caused  by  twisting  the  head  during  labor.  The  swelling  is  due 
to  an  extravasation  of  blood  and  to  inflammatory  conditions  of  the  muscle. 
It  is  rarely  seen  before  the  child  is  two  or  three  weeks  old.  There  is  no 
treatment  necessary.  The  blood  is  absorbed  and  the  swelling  gradually 
disappears. 

Cephalhematoma. 

A  swelling  is  sometimes  seen  on  the  top  of  the  head  during  the  first 
few  days  of  the  infant's  life.  It  is  usually  associated  with  the  application 
of  forceps  or  a  similar  injury  during  labor.  This  condition  is  rare  in  chil- 
dren. The  statistics  of  the  Sloane  Maternity  Hospital  show  that  this  con- 
dition was  met  with  in  20  out  of  1300  consecutive  births,  or  1.6  per  cent. 
There  may  be  several  swellings.  They  are  most  frequently  seen  over  the 
parietal  or  occipital  bone. 

Symptoms. — A  swelling  that  is  very  soft  and  fluctuating  is  noticed. 
This  swelling  gradually  increases  in  size,  and  attains  its  maximum  at  the 
end  of  twelve  or  fourteen  days.  There  is  no  pulsation  palpable.  The  tem- 
perature is  usually  normal. 

Diagnosis. — This  condition  is  frequently  mistaken  for  encephalocele. 
The  latter,  however,  is  always  seen  in  conjunction  with  the  fontanel  or  along 
the  line  of  the  sutures. 

Pressure  causes  cerebral  symptoms.  This  condition  can  be  confounded 
with  hydrocephalus.  In  the  latter  the  symmetrical  enlargement  of  the  whole 
head  is  always  a  characteristic  feature. 


60  ABNORMALITIES  AKD  CONGENITAL  MALFORMATIONS. 

Baby  M.,  seven  days  old,  was  born  with  the  aid  of  forceps,  after  a  very  diffi- 
cult and  dry  labor.  When  the  infant  was  three  days  old  a  swelling  was  noticed  on 
the  scalp  over  the  left  parietal  bone.  This  swelling  gradually  increased  in  size  and 
felt  soft,  doughy,  and  fluctuating.  An  incision  was  made  which  liberated  about  four 
ounces  of  clear,  fluid  blood.  Several  days  later  this  case  was  also  seen  by  Dr.  Willy 
Meyer,  and  as  suppuration  existed  it  was  necessary  to  treat  the  wound  on  general 
surgical  principles.     The  child  recovered. 

Treatment. — The  above  case  illustrates  the  mistake  that  can  be  made. 
A  haematoma  is  a  benign  condition  and  disappears  without  treatment. 
Bandaging  and  compression  are  unnecessary,  but  injury  to  the  part  must 
be  avoided. 

Caput  Succedaneum   (Spurious  Cephalhematoma: 
Supplementary  Head). 

This  is  a  swelling  of  the  scalp  due  to  congestion,  resulting  in  an  ex- 
travasation of  the  blood  and  lymph  into  the  subcutaneous  tissue  which  is 
external  to  the  pericranium.  This  swelling  does  not  fluctuate.  It  is  usually 
seen  in  that  portion  of  the  head  which  first  presents  itself  at  the  vulva  dur- 
ing labor.  No  treatment  is  required,  as  this  condition  usually  becomes 
normal. 

Congenital  Cyst  of  the  Kidney. 

The  literature  records  an  occasional  case  of  this  condition.  There  are 
no  symptoms  which  would  be  the  means  of  determining  this  condition  dur- 
ing life.    The  diagnosis  is  therefore  made  post-mortem. 


Fig.  19. — Congenital  Cystic  Kidney,  half  natural  size.      ( Langerhans. ) 

Congenital  Sacral  Tumor. 

J.  B.,  male  infant,  eleven  months  old,  was  brought  to  my  children's  service 
at  the  German  Poliklinik.  He  was  breast-fed  and  appeared  in  good  health.  The 
mother  noticed  a  large  swelling  over  the  sacral  and  lumbar  regions.     The  infant  did 


CONGENITAL  MALFORMATIONS  OF  THE  RECTUM.        63 

not  seem  to  be  in  paiu.  The  growth  was  non-inflammatory  and  did  not  interfere 
with  the  movements  of  the  legs.  The  diagnosis  of  congenital  lipmna  was  made  and 
an  operation  advised.  The  case  was  sent  by  me  to  Dr.  Geo.  F.  Shrady  for  operation 
at  St.  Francis  Hospital.     The  tumor  was  removed.     The  ease  recovered. 


Fig.  20. — Congenital   Sacral   Tumor.    (Original.) 

Congenital  Malformations  of  the  Eectum. 

E.  E.  Kirby^  states  that  these  occur  under  the  following  types : — 

1.  Congenital  narrowing  of  the  anus  or  rectum,  without  complete 
occlusion.  The  anal  aperture  is  at  times  preternaturally  small,  either  in 
consequence  of  a  contraction  of  the  lower  end  of  the  rectum,  or  from  the 
fact  that  the  skin  may  extend  occasionally  over  the  border  of  the  anal  mar- 
gin. The  diagnosis  is  usually  easy,  for  the  contraction  is  near  the  anus  and 
can  be  readily  detected  by  the  finger,  or  seen  when  due  to  a  fold  of  skin 
extending  across  the  anus.  The  treatment  consists  in  dividing  the  ring  or 
skin  on  the  dorsum,  and  daily  dilatation,  either  with  the  finger  or  soft-rubber 
bougie. 

2.  Closure  of  the  anus  by  a  membranous  diaphragm  (atresia  of  the 
anus)  is  the  simplest  of  all  fonus  of  congenital  malformations,  and  is  treated 
by  a  crucial  incision  through  the  membrane. 

3.  In  imperforate  rectum  one  may  expect  to  find  some  of  the  most  diffi- 
cult cases  of  malformation,  although  some  are  comparatively  simple.  In- 
stead of  a  normal  anus  the  skin  of  the  perineum  extends  across  the  anal 
region  from  side  to  side,  and  the  rectum  may  terminate  quite  a  distance 
from  the  normal  site  of  the  anus.  The  intervening  space  may  be  made  up 
of  connective  tissue,  while  a  circular  elevation  or  depression  marks  the  nor- 
mal site  of  the  anus.     Occasionally  a  distinct  fibrous  cord  may  be  traced 

^"Congenital  Rectal  Malformations."     Archives  of  Pediatrics,  August,   1897. 


64  ABNORMALITIES  AND  CONGENITAL  MALFORMATIONS. 

from  the  rectal  pouch  to  the  skin.  If  the  rectal  pouch  be  not  at  too  great 
a  distance  from  the  skin^  a  sense  of  fluctuation  may  be  felt  by  firm  pressure 
of  one  finger  over  the  anus  and  the  hand  over  the  abdomen. 

4.  The  system  which  separates  the  anal  and  rectal  pouches  in  cases  of 
imperforate  rectum  with  a  normal  anus  is  generally  within  easy  reach  of  the 
anus.  It  may  be  perforated  and  slow  dribbling  of  meconium  allowed.  There 
may  also  be  more  than  one  septum. 

5.  The  anus  may  be  absent  and  the  rectum  open  at  any  point  in  the 
perineum  or  sacral  region.  The  lower  portion  of  the  rectum  in  these  cases 
is  usually  of  a  fistulous  character,  lined  by  true  mucous  membrane,  and  the 
abnormal  anus  is  always  narrow  and  insufficient  for  its  purpose.  Occasion- 
ally the  rectum  terminates  in  two  distiiict  openings,  at  a  greater  or  less 
distance  from  each  other. 

6.  The  anus  may  be  absent  and  the  rectum  terminate  in  the  bladder, 
urethra,  or  vagina.  In  females  the  vaginal  opening  is  the  most  common ; 
in  males  the  vesical.  This  condition  is  usually  rapidly  fatal  unless  relieved 
by  prompt  surgical  interference. 

7.  The  rectum  or  the  large  intestine  may  be  entirely  absent. 
Kirby  lays  down  the  following  rules : — 

1.  An  operation  should  always  be  performed,  and  performed  without 
delay. 

2.  If  there  be  any  chance  of  establishing  an  opening  at  the  normal  site 
of  the  anus,  the  surgeon  should  at  first  direct  his  attention  to  this  procedure. 

3.  The  use  of  a  trocar  as  an  aid  in  finding  the  rectal  pouch  before  or 
after  incision  through  the  perineum  is  not  sanctioned  by  modern  surgical 
authority. 

4.  The  results  of  attempts  to  estal)lish  an  outlet  for  tlie  imperforate 
rectum  through  the  perineum  are  not  favorable  as  regards  the  production 
of  a  useful  anus. 

5.  In  case  of  failure  to  establish  a  new  anus  in  the  anal  region,  colotomy 
should  at  once  be  performed. 

6.  In  the  formation  of  an  artificial  anus  the  left  groin  is  the  best  site 
for  the  operation. 

7.  Attempts  at  establishing  an  anus  in  the  anal  region  after  a  colotomy 
are  attended  with  great  danger,  and  are  generally  unsuccessful. 


PART  III. 

NUTRITION. 


■      CHAPTER  I. 
THE  INFANTILE  STOMACH. 

The  infantile  stomach  is  vertical  and  cylindrical  and  the  fundus  but 
little  developed.  Thus,  whenever  there  is  a  tendency  to  vomit,  the  anti- 
peristaltic motions  do  not  press  against  the  fundus,  but  directly  upward. 
There  is,  therefore,  rather  an  overflow  than  a  vomiting  of  the  gastric  con- 
tents; this  takes  place  so  easily  that  the  infants  are  not  disturbed  by  it.^ 

Anatomy. — The  muscular  development  is  weakest  at  the  fundus.  Ac- 
cording to  Fleischmann,  the  oblique  and  the  longitudinal  fibers  described 
by  Henle,  which  have  their  origin  at  the  pyloric  opening,  "do  not  exist  in 
the  infant."  The  investigations  of  Leo  and  von  Puteren  show  that,  in  spite 
of  this  lack  of  muscular  development,  the  stomach  of  a  nursing  infant  is 
emptied  in  one  and  a  half  or  two  hours.  With  food  that  is  more  difficult 
to  digest,  the  gastric  contents  are  propelled  more  slowly. 

The  Mucous  Membrane  of  the  Stomach. — The  mucous  glands  are  far 
more  numerous  on  the  pars  pjdorica  than  in  adults,  whereas  they  are  far 
fewer  in  number  at  the  cardia. 

The  mucous  membrane  of  the  infant  secretes  gastric  juice,  which,  in 
general,  is  similar  in  properties  to  that  of  the  adults.  The  amount  of  secre- 
tion in  the  infant  is  far  less  than  in  the  adult,  while  its  chemical  constitu- 
tion is  the  same,  namely:  pepsin,  lab-ferment,  and  acids.  The  exact  pro- 
portion of  the  ferment  and  pepsin  has  not  yet  been  studied  sufficiently  to 
admit  of  any  positive  deductions  being  made. 

Physiology. — It  is  very  important  to  know  that  the  mucous  membrane 
of  the  mouth  is  practically  dry  at  birth;  the  secretion  of  saliva  is  very 
small,  and,  according  to  Korowin  and  Zweifel,  increases  toward  the  end  of 
the  second  month. 

The  fermentative  (sugar-forming)  property  of  saliva,  which  is  trifling 
at  the  commencement,  increases  with  the  quantity  of  the  saliva  secreted. 
This  is  essentially  true  of  other  secretions;  thus,  the  pancreatic  juice  does 
not  have  the  same  emulsifying  properties  in  the  infant  as  in  adults. 

The  nursing  or  sucking  center  is  located,  according  to  experiments 
made  on  animals  by  Basch,  in  the  medulla  oblongata  on  the  inner  side  of 
the  corpus  restiforme. 

The  sucking  act  is  reflex;  according  to  Auerbach,  the  muscles  of  the 
tongue  participate  most  actively. 


*  Jacobi,  "Therapeutics  of  Infancy  and  Childhood,"  page  25. 

5  (65) 


66 


KUTRITION. 


Acids  in  the  Infant's  Stomach. — The  gastric  contents  in  a  nursling 
contain  two  acids :  ( 1 )  In-drochloric  acid ;  ( 2 )  lactic  acid.  The  relative 
acidity  is  smaller  than  in  adults,  the  highest  point  being  reached  one  and 
a  half  hours  after  nursing.  According  to  von  Puteren,  the  acidity  is  two 
and  one-half  to  three  times  as  small  as  in  the  stomach  of  adults.  Accord- 
ing to  Leo,  the  acidity  of  the  gastric  juice  of  nurslings  1%  hours  after 
drinking  is  only  0.13  per  cent.,  whereas,  in  the  adult,  after  the  same  time, 
the  acidity  is  from  1.5  to  3.2  per  cent.  According  to  Wohlmann,  free  HCl 
can  be  found  in  healthy  nurslings  from  II/4  'to  2  hours  after  taking  food. 
The  percentage  of  free  HCl  ranges  from  0.83  to  1.8  per  cent. 

Lactic  Acid. — The  quantity  of  lactic  acid  is,  according  to  Heubner, 
between  0.1  and  0.4  per  cent. 

Pepsin  and  Hydrochloric  Acid. — There  are  two  chief  functions  of  the 
pepsin  and  hydrochloric  acid  which  are  the  same  in  both  infant  and  adult : 
First,  the  power  of  killing  bacteria :  a  real  bactericidal  power.  Second,  as 
a  solvent  for  albumin.  Thus,  it  is  apparent  that  pathogenic  micro-organ- 
isms that  might  have  entered  the  stomach  can  be  destroyed,  although  we 
know  the  small  quantity  of  acid  is  hardly  able  to  cope  with  large  quantities 
of  food  contaminated  with  bacteria. 

Unorganized  Ferments. — The  unorganized  ferments  seem  to  be  nitrog- 
enous bodies;  their  exact  composition  is  unknown,  and  it  is  doubtful  if 
they  have  ever  been  obtained  perfectly  pure  (Landois  and  Stirling). 

Action  of  the  Saliva  on  Various  Bacteria. — Triolo  describes  a  series 
of  interesting  experiments  with  saliva.  He  first  irrigated  the  mouth  with 
bichloride  or  permanganate  of  potash  solution,  followed  this  by  irrigation 
with  sterilized  water  until  the  disinfecting  substances  were  removed,  and 
then  inoculated  the  surface  of  various  culture-media  with  the  sputum.  His 
results  proved  that  saliva  possesses  a  distinct  bactericidal  propert}^,  for 
cultures  of  five-day-old  bacteria  were  destroyed,  as  well  as  fresh  bacteria 
eighteen  hours  old. 

This  property,  however,  was  lost  when  saliva  was  filtered.  The  saliva 
of  the  parotid  and  submaxillary  glands,  taken  singly,  were  equally  effica- 
cious as  their  combined  secretion.  He  believes  that  the  greatest  bactericidal 
action  is  due  to  the  secretion  of  the  mucous  glands  in  the  mouth. 

The  Influence  of  Gastric  Juice  on  Pathogenic  Germs. — Gastric  juice  is, 
according  to  the  experiments  of  Drs.  Kurlow  and  Wagner,  an  exceedingly 
strong  germicidal  agent,  and  when  living  bacilli  get  into  the  intestinal 
canal  it  is  due  to  various  conditions  entirely  independent  of  the  gastric 
juice.  When  the  latter  is  normal  and  in  full  activity,  only  the  most  prolific 
microbes — such  as  tubercle  bacilli,  the  bacilli  of  anthrax,  and  perhaps  the 
staphylococci — escape  its  destructive  action  ;  nil  others  are  destroyed  in  less 
than  half  an  hour.  Similar  influences  exist  in  the  intestines,  as  proved  by 
inoculation  with  the  cholera  bacilli. 


THE  INFANTILE  STOMACH. 


67 


Taule  No.  8. — Shotriiit/  the  Unorganized  Ferments  Present  in  the  Body 
and  Their  Actions. 


Fluid  or  Tissues. 

Ferment. 

Actions. 

Saliva    •    •    • 

Ptyalin 

Converts  starch  chiefly  into  mal- 
tose. 

1.  Pepsin  .           ,....•• 

Converts  proteids  into  peptones  in 
an  acid  medium,  certain  by- 
products being  formed. 

Curdles  casein  of  milk. 

Splits  up  milk  sugar  into  lactic 
acid. 

Splits  up  fats  into  glycerine  and 
fatty  acids. 

Gastric  juice     .    - 

2.  Milk-curdling 

3.  Lactic-acid  ferment.      .    .    . 

4.  Fat-splitting 

1.  Diastasic,  or  aniylopsin    .    . 

2.  Trypsin 

Converts  starch  chiefly  into  mal- 
tose. 

Changes  proteid  into  peptones  in 
an  alkaline  medium,  certain 
by-products  being  formed. 

Emulsifies  fat. 

Splits  fat  into  glycerine  and  fatty 
acids. 

Curdles  casein  of  milk. 

Pancreatic  juice  . 

3.  Emulsive  (?) 

4.  Fat-splitting  or  steapsin  .   . 

5.  Milk-curdling 

1.  Diastasio 

Does  not  form  maltose,  but  mal- 

Intestinal juice   . 

2.  Proteolytic 

3.  Invertin 

tose  is  changed  into  glucose. 

Fibrin  into  peptune  (?). 

Changes    cane-sugar    into    grape- 
sugar. 

In  small  intestine  (?). 

4.  Milk-curdling 

Blood     

Chyle        .... 
Liver  (?)  .    .    .    . 
Milk  .           ... 
Most  tissues .   .    . 

Diastasic  ferments     .... 

Muscle 

Urine 

Pepsin  and  other  ferments  . 

Blood     

Fibrin-forming  ferment   .    . 

Judging  from  the  results  of  experiments  made  l)y  Zagari,  Straus,  and 
Wurtz,  who  exjiosed  various  pathogenic  organisms,  among  others  that  of 
tuberculosis,  to  the  action  of  gastric  juice,  we  must  come  to  the  conclusion 
that,  so  long  as  the  gastric  juice  retains  a  sufficient  degree  of  acidity,  tuber- 
culosis of  the  alimentary  canal  will  be  unlikely  to  occur. 

Albumin  and  the  Gastric  Juice. — Another  property  of  gastric  juice  in 
infants  is  the  transformation  of  albumin  in  the  following  manner:      (1) 


G8  NUTRITIOX. 

albiimose;  (2)  then  peptone^  (3)  and  lastly  syntonin.  It  is  thus  appar- 
ent that,  although  the  infantile  stomach  plays  a  subordinate  role  as  a  nour- 
ishing organ,  it  cannot  be  denied  that  fluid  sul^stances — like  water,  a  solu- 
tion of  salt,  and  solution  of  sugar — are  absorbed,  and  in  a  less  degree  albu- 
min aleo.  The  relative  size  and  capacity  of  the  stomach  prevent  the  func- 
tion from  being  as  thoroughly  developed  as  in  the  adult. 

Stomach  Capacity. 

'  At  birth  the  infant's  stomach  has  a  capacity  of  from  9  to  11  drachms, 
or  35  to  43  cubic  centimeters.  At  the  end  of  one  month  it  is  about  2  ounces, 
or  60  cubic  centimeters. 

At  the  end  of  three  months  the  gastric  capacity  is  about  four  times 
the  amount  at  birth.  The  very  rapid  increase  from  birth  to  this  time  soon 
ceases,  and  the  stomach  capacity  grows  in  size,  but  at  a  much  slower  rate 
of  development  (Baginsky). 

The  series  of  experiments  at  the  Children's  Hospital  of  St.  Petersburg, 
made  by  Ssnitkin,  showed  that  the  weight,  and  not  the  age,  determined  the 
capacity  of  the  stomach,  and  should  be  used  as  a  guide  for  the  quantity  of 
infant-food  required. 

If  the  normal  (initial)  weight  of  an  infant  is  3000  to  4000  grams,  or 
about  6.6  to  8.8  pounds,  then  ^/^oq  part,  plus  the  daily  increase  in  weight 
added,  which  normally  amounts  to  from  ^/g  to  1  ounce,  would  give  the 
amount  of  food  required. 

Biedert  also  regards  the  body  weight  as  an  important  factor  in  deter- 
mining the  amount  of  milk  to  be  given.  Baginsky  argues  that,  while  this 
rule  will  hold  good  for  a  great  many  infants,  he  must  insist  upon  relying 
upon  the  scales  to  show  just  how  much  nutriment  has  been  digested,  and 
thus  a  regular  system  of  weighing,  plus  the  inspection  of  the  stools,  will 
aid  in  establishing  the  quantity  of  food  necessary.  "There  is  no  unanimity 
among  experienced  clinical  observers  upon  the  subject  of  infant-feeding." 
The  majority  of  clinicians  the  world  over  order  cows'  milk  in  varying 
dilutions.  Some  use  the  cereals — ^like  wheat,  barley,  rice,  and  farina — to 
dilute  and  subdivide  the  curd.  Other  clinical  observers — Budin  and  Variot, 
French  observers — advise  giving  infants,  at  birth,  ivliole  milh;  that  is,  pure, 
undiluted  coivs'  mill'. 

The  following  illustrations  will  serve  to  show  the  difference  in  the 
capacity  of  infants'  stomachs  at  various  ages,  tal:en  by  the  author  at  the 
morgue  of  Bellevue  Hospital. 


Fig.  21 —Infant's  stomach.  Actual  Size.  From  a  Case  of  Malnutrition.  Capacity, 
About  2  Ounces.  When  Stomach  was  Filled  it  Held  4  Ounces  Easily.  (Author's  Col- 
lection.) 


Fiff.  22.— Infant's  Stomach.  Actual  Size.  Died  Suddenly  from  Convulsions.  Age 
Seven  Months.  Cause  of  Death,  Eclampsia.  Capacily  when  Filled  with  Water,  8?^ 
Ounces.    (Drawn  from  Specimen  in  Author's  Collection  ) 


(69) 


Fig.  23. —  Infant's  Stomach.  Capacity,  10  Ounces.  Age  of  Child,  Eleven 
Months.  Cause  of  Deaih,  Enteritis.  (Drawn  from  Specimen  ia  Author's  Col- 
lection.) 


Fig.  24.— Capacity  of  Jleasuremcnt,  14  Ounces.    Diseased  Condition.    Normal  Capacity. 
Holding  About  2  Ounces,  or  50  Cubic  Centimeters.     (Author's  Collection. ) 


(70) 


SIGNIFICANCE  OF  VOMITING.  71 

Significance  of  Vomiting. 

The  symptom  of  vomiting  needs  careful  interpretation.  Wlien  tlie 
symptom  occurs  in  gastric  and  intestinal  conditions  it  is  not  difficult  to 
make  a  diagnosis.  It  is  important  to  note  the  frequency  of  vomiting :  Does 
or  does  it  not  occur  after  every  feeding  ?  Has  the  infant  had  a  stool  during 
the  last  twelve  hours?  Intestinal  obstruction  is  usually  accompanied  by 
frequent  vomiting  and  the  absence  of  stool.  Intestinal  worms  are  frequently 
a  cause  of  vomiting.  Likewise,  an  early  symptom  of  appendicitis  is  vomit- 
ing. Feeding  high  percentages  of  fat  may  provoke  vomiting;  likewise,  ex- 
cessive quantities  of  sugar  may  produce  vomiting  as  well  as  colic  from 
flatulence.  Pyloric  spasm  and  pyloric  stenosis  are  usually  accompanied  by 
vomiting. 

Vomiting  is  a  reflex  act.  It  can  be  produced  directly  by  irritating 
the  stomach,  as,  for  example,  when  mustard  is  swallowed.  It  can  also  be 
produced  by  a  great  many  vegetable  products,  as,  for  example,  by  ipecac 
root.  Mineral  poisons,  such  as  sulphate  of  zinc  or  turpeth  mineral,  or  sul- 
phate of  copper,  will  produce  violent  emesis.  Bacterial  fermentation  from 
stagnant  food  can  also  produce  vomiting.  These  causes  are,  therefore,  direct 
in  their  action  and  produce  immediate  results.  It  is  a  great  mistake  to 
look  upon  the  stomach  or  the  stomach  contents  as  the  etiological  factor  in 
vomiting,  and  as  the  only  organ  capable  of  producing  emesis. 

The  toxins  in  the  blood  of  many  acute  infectious  diseases  produce  vom- 
iting. One  of  the  earliest  symptoms  of  scarlet  fever  is  vomiting.  Several 
days  before  the  eruption,  of  scarlet  fever  appears,  vomiting  of  a  most  violent 
nature  generally  occurs.    This  is,  no  doubt,  due  to  toxaemia. 

An  irritation  of  the  vagus  or  the  pneumogastric  nerves  can  result  in 
vomiting.  Any  irritation  brought  about  through  the  central  nervous  sys- 
tem will  cause  vomiting;  thus  it  is  that  shock,  fright,  or  disturbance  of 
metabolism  may  produce  vomiting  of  a  most  serious  nature. 

Giddiness,  caused  by  swinging  or  a  rolling  motion,  as  on  a  ship,  may 
produce  cerebral  hypersemia,  ending  in  vomiting.  When  a  child  falls  on 
the  back  of  its  head  and  produces  concussion  of  the  brain,  we  have  con- 
tinued vomiting  as  a  first  symptom.  When  vomiting  persists  in  spite  of 
gastric  treatment,  meningeal  disease  should  be  suspected.  In  meningitis, 
especially  in  hydrocephalus,  vomiting  is  a  frequent  symptom.  The  writer 
does  not  presume  that  any  physician  will  diagnose  brain  fever,  scarlet  fever, 
or  gastric  fever  by  the  single  symptom  of  vomiting. 

On  the  other  hand,  it  is  well  to  know  that  vomiting,  with  a  suspicious 
rash  and  a  sore  throat,  will  strengthen  the  suspicion  of  an  existing  scarlet 
fever.  A  rule  followed  by  the  writer  is  to  lay  considerable  stress  on  vom- 
iting. It  means  nothing  if  we  are  dealing  with  a  spoiled  stomach  following 
a  large  dish  of  plum  pudding.    But  woe  to  the  physician  who  gives  a  good 


73  NUTRITION. 

prognosis  where  vomiting  is  an  early  manifestation  of  intracranial  disease 
that  ends  fatally. 

Stomach  Washhstg. 

When  vomiting  persists^  especially  in  pyloric  spasm,  stomach  washing 
(lavage)  is  indicated.  One  teaspoonful  of  bicarbonate  of  soda  added  to  one 
pint  of  warm  water  can  gradually  be  introduced  by  pouring  through  a  fun- 
nel attached  to  a  soft-rubber  or  flexible  catheter.  While  many  clinicians 
advise  placing  the  child  in  an  upright  position  during  the  lavage,  I  have 
found,  especially  in  younger  infants,  that  it  is  easier  to  fill  the  stomach 
and  syphon  off  the  gastric  contents  while  the  child  is  flat  on  its  back.  In 
the  dorsal  position  the  tube  can  be  gently  but  quickly  forced  over  the  tongue, 
down  the  pharynx,  through  the  oesophagus,  into  the  stomach.  In  washing 
the  stomach  the  funnel,  holding  three  or  four  ounces,  should  be  filled,  and 
raised  above  the  level  of  the  stomach.  After  the  fluid  has  entered  the 
stomach,  we  can  syphon  off  the  contents  by  lowering  the  funnel  below  the 
level  of  the  stomach.  This  process  should  be  repeated  several  times  or  until 
the  return  flow  from  the  stomach  is  clear. 

It  is  advisable  to  wash  the  stomach,  preferably  before  food  has  been 
given.  In  obstinate  vomiting  lavage  should  be  performed  daily.  No  force 
should  be  used  in  pushing  the  tube  into  the  stomach.  The  eyelet  of  the 
catheter  should  be  carefully  inspected  to  see  that  there  are  no  sharp  edges. 
An  injury  to  the  gastric  mucosa  by  laceration  with  a  sharp  border  of  a 
stomach-tube  will  certainly  result  in  an  erosion. 

The  Abdomen. 

The  abdomen  of  a  child  is  comparatively  larger  than  that  of  the  adult. 
Especial  attention  should  be  given  to  the  condition  of  the  abdomen;  for 
instance,  a  retracted  abdomen  is  usually  seen  in  meningitis.  (See  chapter 
on  "Meningitis.")  A  distended  abdomen  is  frequently  seen  in  rachitis 
(pot-belly).  (See  article  on  "Eachitis.")  A  very  prominent  abdomen  is 
seen  in  chronic  peritonitis,  to  which  I  direct  attention  in  the  special  article 
dealing  with  that  subject. 

The  Intestines. 

Small  Intestine. — At  birth  the  length  of  the  small  intestine  is  nine  and 
one-half  feet.  The  length  of  the  intestine  may,  however,  vaiy  with  the  size 
of  the  child.  In  the  duodenum  Brunner's  glands  are  found.  Below  the 
duodenum  Peyer's  patches  are  found.  The  most  important  physiological 
function  of  the  small  intestine  consists  in  aiding  the  assimilation  of  food 


THE  INTESTINES.  73 

by  tlie  action  of  the  pancreatic  juice  and  other  secretions.  The  emulsifica- 
tion  of  the  fat  in  the  food  takes  place  in  the  small  intestine. 

Len^h  of  the  Intestine. — The  relative  length  of  the  intestine  in  nur- 
slings is  greater  than  in  adults,  so  that  the  intestines  are  six  times  as  long  as 
the  body.  Forster  believes  this  is  one  reason  why  nurslings  receive  more 
nourishment  from  milk  than  do  adults.  The  small  intestine  develops  during 
the  first  two  months  of  life  more  than  the  large  intestine,  and  after  the 
second  month  the  reverse  is  true.  The  duodenum  remains  relatively  the 
longer  until  the  end  of  the  fourth  month.  The  transverse  colon  is  the  widest 
and  most  elastic  portion  of  the  large  intestine.  The  continuation  of  the 
large  intestine  in  infants,  into  the  rectum,  is  indicated  by  a  narrowing  at 
this  point. 

Large  Intestine. — According  to  Treves,  the  large  intestine  measures : — 

At  birth    1  foot  10  inches,  or  55      centimeters 

At  12  months 2  feet      6  inches,  or  76      centimeters 

At    6  years 3  feet,  or  91.5  centimeters 

At  13  years  ~ 3  feet     6  inches,  or  107      centimeters 

Course  of  the  Colon. — From  the  right  iliac  fossa  up  to  the  liver,  then 
transversely  across  the  abdomen  to  the  spleen  and  then  downward,  ter- 
minating in  the  rectum.  The  colon  forms  at  its  first  turn  the  hepatic 
flexure,  at  the  spleen  the  splenic  flexure,  and  finally  the  sigmoid  flexure. 
The  curve  of  the  sigmoid  flexure  occurs  in  the  left  iliac  fossa. 

Sigmoid  Flexure. — The  anatomical  illustrations  of  the  sigmoid  flexure 
(see  article  on  "Chronic  Constipation")  are  important  to  remember  in 
view  of  the  mechanical  cause  of  constipation  so  frequently  seen  in  young 
children. 

The  transverse  colon,  when  distended  with  gas,  is  very  easily  mapped 
out  by  percussion. 

The  Csecum. — Dwight  found  the  ca3cum  completely  covered  with  peri- 
toneum in  33  out  of  37  cases  in  5^oung  children.  Treves  states  that  in  100 
cases  observed  by  him  he  found  the  peritoneum  infolding  the  ctecum  in 
all  of  these  cases  on  its  posterior  surface. 

The  Cfficum  occupies  a  higher  position  anatomically  in  a  child  than 
in  adult  life. 

Vermiform  Appendix. — Behind  the  CEecum  lies  the  vermiform  appendix. 
It  is  important  to  remember  that  it  lies  in  the  line  midway  hetween  the 
umhiliciis  and  the  crest  of  the  ilium.  When  the  appendix  is  inflamed  and 
swollen  it  can  frequently  be  mapped  out  by  rectoabdominal  (bimanual) 
palpation. 


74  NUTRITION. 

Formation  of  Gas  in  the  Intestine. — When  we  consider  tlie  lesser 
development  of  the  muscles  of  the  intestine,  we  can  readily  understand 
that  peristaltic  movements  are  more  irregular  and  less  forcible,  and  that 
the  muscles  possess  less  tone;  on  this  account  there  is  a  larger  amount  of 
gas  contained  in  the  intestine,  which  constantly  distends  it.  Thus  it  is 
apparent  why  the  abdomen  always  appears  larger  in  the  infant  in  propor- 
tion to  the  other  parts  of  the  body. 

Action  of  Intestinal  Muscles. — The  action  of  the  intestinal  muscles  is 
chiefly  to  transport  the  food  by  a  series  of  peristaltic  movements.  Parts 
of  the  intestine  are  active,  while  others  remain  passive.  Heubner  maintains 
that  post-mortem  examinations  never  show  all  parts  of  the  intestine  in  the 
same  condition,  owing  to  the  irregularity  of  the  muscular  movements. 

Development  of  Glandular  System. — The  development  of  the  glandular 
system  in  infants  is  very  poor,  whereas  the  lymphoid  tissues  and  follicles 
are  comparatively  well  developed. 

Lieberkiihn^s  glands  are  fewer  in  number  than  in  adults,  whereas  the 
Brunner  glands  in  the  duodenum  are  numerous  and  well  developed. 

The  Secretory  and  Absorbing  Power  of  the  Epithelium  and  the  Glands. 
— Heubner  maintains  that  the  secretion  takes  place  from  cells,  located  in 
the  small  intestine,  which  are  scattered  about  and  are  few  in  number, 
whereas  in  the  large  intestine  they  are  far  more  numerous. 

Absorption  of  Tat. — The  absorption  of  fat  takes  place  through  the 
intestinal  epithelium  in  the  duodenum  and  jejunum;  the  glands  also  par- 
ticipate in  this  action.  According  to  the  histological  investigations  by 
Baginsky,  the  real  absorbing  system  of  the  intestinal  wall  is  found  in  the 
connective-tissue  bodies  of  the  mucous  membrane  of  the  infantile  intestine, 
in  which  are  located  lymphatic  vessels  connected  with  the  larger  lymph- 
channels  of  the  intestine.  The  physiological  and  chemical  functions  are 
much  less  developed  in  infants  than  in  adults,  because  the  intestinal  glands 
are  relatively  less  developed. 

breast-milk  and  wet-nursing. 
Colostrum. 

Colostrum  is  found  in  the  breast  of  a  woman  several  hours  after  giving 
birth  to  her  infant.  It  resembles  milk,  but  is  a  much  thinner  fluid.  It  is 
always  the  forerunner  of  a  healthy  normal  secretion  of  breast-milk,  which 
usually  appears  on  the  third  day  after  the  birth  of  the  infant. 

Colostrum  corpuscles  have  been  described  by  Czerny  as  lymphoid  cells, 
whose  function  is  to  absorb  and  reconstruct  unused  milk  globules  and  to 
convey  them  from  the  milk-glands  into  the  lymph-channels.  These  cor- 
puscles usually  disappear  in  one  week  or  ten  days  after  birth.    When  colos- 


BREAST-MILK.  75 

trum  corpuscles  are  present  after  one  month,  then  such  milk  will  cause 
gastric  disturbances.  It  is  a  wise  plan  to  examine  the  milk  microscopically 
whenever  the  slightest  evidence  of  gastric  or  intestinal  disturbance  is  noted. 

According  to  Baginsky,  colostrum  contains  large  quantities  of  serum- 
albumin,  and  is  also  very  rich  in  fat  and  colostrum  corpuscles,  and  contains 
a  large  quantity  of  salts.  The  last  two  ingredients  are  supposed  to  be  the 
cause  of  the  laxative  action  of  the  colostrum. 

When  colostrum  corpuscles  persist  in  hreast-milk,  in  spite  of  the  regu- 
lated diet  and  the  hygienic  condition  of  the  mother,  then  breast-feeding 
must  be  discontinued.  A  very  fretful  and  nervous  mother  will  frequently 
have  colostrum  corpuscles  in  her  milk.  An  instance  of  this  kind  was  seen 
recently  by  me.     Substitute  feeding  will  frequently  modify  this  condition 


COLOSTRUjM 
CORPUSCLES 


Fig.  25. — From  a  drop  of  milk  on  the  third  day  after  delivery. 
(Zeiss  Ocular  4,  dd  Lens.)      (Original.) 

unless  there  is  a  specific  cause  for  the  same.  When  a  nursing  mother  is 
very  weak  and  anaemic  after  her  confinement,  then  iron  is  indicated.  I  saw 
a  case  in  consultation  recently  in  which  the  combined  use  of  fresh  air, 
cereals,  and  iron  changed  a  thin  milk  containing  colostrum  corpuscles  into 
a  thick,  creamy  milk  in  less  than  one  month.  Continued  menstruation  or 
uterine  disorder  with  disease  in  the  endometrium  may  cause  profound 
anaemia  and  thus  render  breast-milk  very  thin.  Such  milk  is  totally  unfit 
for  the  proper  nutrition  of  the  infant. 

Bkeast-milk. 

According  to  Pfeiffer,  human  milk  contains,  several  days  after  the 
birth  of  the  infant,  a  large  quantity  of  albumin,  salt,  and  a  small  quantity 
of  fat.  He  also  found  that  the  longer  the  period  of  nursing,  the  smaller  the 
quantity  of  albumin,  which,  in  the  eleventh  month,  sinks  quite  low.    There 


76 


NUTRITION. 


Tarle  No.   9. 
Properties  of  Human  Milk, 

Appearance.  Bluish,  semitransparent,  no  odor,  sweetish. 

Specific  Gravity.  1026  to  1036. 

Reaction.  Amphoteric,  relation  of  alkalinity  and  acidity  as  3  to  1. 


On  Boiling. 


Does  not  coagulate,   and  forms  a  very  thin,  hardly-per- 
ceptible skin. 


Coagulates. 


At  ordinary  temperature  after  several  hours. 


Coagulates   on    addi- 

, .  f     T    h  f  J  Coagulates    imperfectly   in    small    isolated   flakes,   which 

do  not  precipitate  as  a  uniform  coaguluiii. 


ment. 


Fat. 


Yellowish  white,  resembling  cow-butter.     Specific  gravity 
at  15°  C,  0.966.     Melts  at  34°  C. 


Varieties  of   Fat.  Butyrin,  palmitin,  stearin,  olein,  myristin,  caproin. 


Behavior     of     Various  f  Few  volatile  acids.     More  than  half  of  the  non- volatile 
Acids.  I      consist  of  oleic  acid. 


Milk-plasma  Casein. 


Difficult  to  precipitate  with  acids  and  salts.  The  pre- 
cipitate redissolves  in  excess  of  acids.  During  pepsin 
digestion  there  is  no  pseudonuclein  produced. 


r  Lactalbvunin  and  lactoglobin ;   relation  of  casein  to  albu- 
Composition    of    Albu- j       min,    0.5    to    1.2    or    1    to    2.4;    of    tlie    1.3    per    cent. 
minoids.  albumin,   there   are   64   parts  of  casein,   and  37   parts 

I      of  globulin  and  albumin. 


Solids. 


Less  solids  than  in  cows'  milk,  especially  CaO — PjOo 


Quantitative  Analy- 
sis, according  to 
Soxhlet. 


Water,   87.41;   albuminoids,  2.29;    fat,   3.78;    milk-sugar, 
6.21;   solids,  0.31. 


Bacteria. 


Usually  sterile,  rarely  staphylococcus  albus  and  aureus. 


rKoi'KiniKs  OK  cows-  .\III,K. 


77 


Appearance. 
Specific  Gravity. 

Reaction. 
On  Boiling. 


Table  No.  10. 

Properties  of  Cows'  Milk. 

(  Opaque   white   or    whitibli    yellow,    in  thin   layers   bluish 
c      wliite,  slijjht  odor,  faintly  sweet. 

1028  to  10.36. 

f  Amphoteric;  relation  between  alkalinity  and  acidity, 
2  to  1 ;  Soxhlet  maintains  that  cows'  milk  contains 
three  times  the  acidity  of  human  milk. 


Does  not  coagulate  and  forms  a  skin  containing  casein 
and  lime-salts. 


Coagulates. 

Coagulates  on  addi- 
tion of  Lab-fer- 
ment. 

Fat. 


Varieties  of  Fat. 


Behavior    of    Various 
Acids. 


Coagulates  very  soon,  owing  to  lactic-acid  formation. 

(Coagulates  to  a  solid  mass  at  body-temperature,  from 
which  a  yellowish  fluid  can  be  expressed. 

Yellowish-white  mass.     Sp.  gr.  at  1.5°  C,  0.949  to  0.996. 

Palmitin,  olein,  stearin,  myristin,  caprilin,  caprin, 
caproin,  butyrin,  laurin,  lecithin,  cholesterin,  and  yel- 
low coloring  matter. 

Volatile  fatty  acids,  about  70  per  cent.;  not  volatile, 
0.3  to  0.4  per  cent,  of  oleic ;  the  remainder  consists  of 
palmitic  and  stearic  chiefly. 


Milk-plasma  Casein.     |  ^^^^  *°  precipitate  with  acids  and  salts;  excess  of  acid 
(      does  not  dissolve ;  belongs  to  the  nucleo-albumin  group. 


Composition    of   Albu 
minoids. 


Solids. 

Quantitative  Analy- 
sis, according  to 
Soxhlet. 


Less  lactalbumin  and  globin;  the  largest  portion  of  the 
albuminoids  is  casein.     Relation  of  casein  to  albumin. 


\  cllU 

I      0.3  to  3.0,  or  1  to  10. 
Cows'  milk  contains  more  solids  than  human  milk 


Water,  87.17;    albuminoids,  3.55;   fat,  3.69;   milk-sugar. 
4.88;  solids,  0.71. 


Bacteria. 


Contains  all  milk  bacteria,  frequently  also  pathogenic 
bacteria,  as  typhoid,  diphtheria,  and  tubercle  ba- 
cilli, etc. 


78 


NUTRITION". 


is  also  a  decrease  in  the  quantity  of  salts,  whereas  the  amount  of  sugar 
steadily  increases.  The  fat  varies  constantly.  According  to  Johannessen, 
the  quantity  of  albumin  in  the  first  six  months  is  1.192  per  cent. ;  in  the 
next  six  months  0.989  per  cent.,  and  at  the  end  of  the  year  0.907  per  cent. 

Breast-milk  varies  according  to  the  length  of  time  that  it  remains  in 
the  breast,  and  also  the  length  of  the  nursing  period;  so  it  has  been  shown 
that  the  first  milk  taken  at  the  beginning  of  the  nursing  act  is  the  poorest 
in  nutrient  value,  whereas  the  last  milk  is  richest  in  fat.  The  longer  the 
milk  remains  in  the  glands  of  the  breast,  the  more  will  the  solid  substances 
of  the  same  be  absorbed,  so  that  only  a  watery  solution  remains.  If  sucking 
is  commenced,  this  stimulation  soon  changes  the  character  of  this  watery 
milk,  so  that  normal  milk  will  soon  be  secreted.  Forster  studied  the  chem- 
ical constitution  of  the  first,  middle,  and  the  last  portions  of  milk  from  a 
nursing  woman,  with  the  following  result. 

In  one  hundred  parts  he  found : — • 

Tabi^  No.  11. 


Water   

Nitrogenous  Substances 

Fat 

Sugar  

Ash    


First  Portion  of  the 
Nursing  Act. 


90.24 
1.13 
]-70 
5.56 
0.46 


Second  Portion  Dur- 
ing Nur.sing. 


89.68 
0.94 
2.77 
5.70 
0.32 


Third  Portion  at  the 
End  of  the  Nursing 
Act. 


87.50 
0.71 
4.51 
5.10 
0.28 


The  quantity  examined  was  37.3  grams. 

From  a  study  of  the  foregoing  tables  we  find  a  decrease  of  nitrogenous 
substances  during  the  course  of  the  nursing,  a  steady  increase  in  the  amount 
of  fat,  and  an  unvarying  percentage  of  sugar.  Thus,  it  is  apparent  that,  in 
order  to  submit  a  specimen  of  hr east-milk  to  a  chemical  examination,  it  is 
necessary  to  stimulate  the  secretory  fimctions  of  the  mammary  glands  by 
putting  the  child  to  the  breast  at  least  two  minutes ;  thus  an  even  milk  can 
be  procured.  If  this  rule  is  overlooked,  then  we  shall  find  proportions  in 
the  chemical  components  of  milk  which  might  otherwise  be  entirely  dif- 
ferent. The  most  recent  chemical  analysis  of  breast-milk  shows  that  in  a 
hundred  parts  there  are : — 

Solids   11.5 

Liquids    88.5 

Of  the  solid  constituents  there  are: — 

Casein    1.2  to  1.03 

Albumin     0.5 

Fat    0.8  to  4.07 

Milk-sugar    6.0  to  7.03 

Ash    0.2  to  0.21 


BREAST-MILK. 


79 


The  above  is  the  chemical  examination  of  a  good  average  breast-milk; 
I  again  call  attention  to  the  fact,  however,  that  not  only  does  the  milk  vary 
in  different  women,  but  it  also  varies  in  the  same  woman  during  one  single 
nursing  act. 

The  albuminoids  of  milk  consist  of  real  casein,  lactalbumin,  globulin, 
and  opalisin.  This  latter  body  has  only  recently  been  discovered  by  A. 
Wroblewski,  and  more  recently  by  Schlossmann. 

Phosphorus  exists  in  milk  as  nuclein-phosphorus,  Wittmaack  has 
demonstrated  the  fact  that  the  phosphorus  in  woman's  milk  exists  as  an 
organic  nitrogen  compound  in  the  casein. 

According  to  the  examination  of  Stolasa,  lecithin  contains  a  larger 
quantity  of  phosphorus  in  woman's  milk  than  in  cows'  milk. 

The  specific  gravity  of  breast-milk  varies  from  1026  to  1036. 


Fig.  26. — Heeren's  Pioscop,  for  Optical  Milk  Test. 

The  Mammary  Glands. — The  mammary  glands  of  the  same  woman 
may  yield  somewhat  different  milk,  as  shown  by  Sourdat  and  later  by 
Brunner.  Also  the  different  portions  of  milk  from  the  same  milking  may 
have  different  compositions.  The  first  portions  are  always  poorer  in  fat 
(Parmentier,  Peligot,  and  others). 

According  to  I'Heritier  Vernois  and  Becquerel,  the  milk  of  blondes 
contains  less  casein  than  that  of  brunettes :  a  difference  which  Tolmatscheff 
could  not  substantiate.  Women  of  weak  constitutions  yield  a  milk  richer  in 
solids,  especially  in  casein,  than  women  with  strong  constitutions. 

According  to  Vernois  and  Becquerel,  the  age  of  the  woman  has  an  effect 
on  the  composition  of  the  milk,  so  that  we  find  a  greater  quantity  of  protein 
and  fat  in  women  15  to  20  years  old  and  a  smaller  quantity  of  sugar.  The 
smallest  quantity  of  protein  and  the  greatest  quantity  of  sugar  are  found 
at  20  or  from  25  to  30  years  of  age.  The  milk  with  the  first-born  is  richer 
in  water — with  a  proportionate  diminution  of  the  quantity  of  casein,  sugar, 
and  fat — ^than  after  several  deliveries.  The  influence  of  menstruation  seems 
to  slightly  diminish  the  milk  sugar  and  to  considerably  increase  the  fat  and 
casein. 

Pioscop. — One  drop  of  milk  can  be  examined  in  the  pioscop  and  com- 
pared with  the  colors  on  the  same.  This  is  a  rapid  but  rough  method  of 
estimating  the  richness  of  the  milk. 


80 


NUTRITION. 


Table  No.  12. — Comparative  Analyses  of  Breast-milk. 


Human  Milk, 


Normal  Milks. 

Average   

Average   

Average   

Average   

14  analyses  from  same  woman 
Mean  of  6,  aged  23-33  years . 

Average 

From  woman  aged  18. .... . 

From  woman  aged  33 

4  days  after  delivery 

9  days  after  delivery 

12  days  after  delivery 

Average  of  84  samples 

Average  of  107  samples 


Fat. 

Proteins. 

Suerar. 

Ash. 

2.90 

3.07 

5.87 

0.16 

3.68 

1.70 

7.11 

0.20 

2.67 

3.92 

4.37 

0.14 

3.52 

2.01 

5.91 

2.53 

3.42 

4.82 

6.23 

3.82 

2.04 

5.93 

0.42 

3.55 

1.52 

6.50 

0.45 

3.20 

2.39 

6.83 

0.29 

2.99 

2.51 

6.51 

0.30 

4.30 

3.53 

4.11 

0.21 

3.53 

3.69 

4.30 

0.17 

3.34 

2.91 

3.15 

0.19 

4.13 

2.00 

6.94 

0.20 

3.78 

2.09 

6.21 

0.31 

Authority. 


A.  W.  Blythe. 

Marehand. 

Vernois  &  Becquerel. 

Hammarsten. 

Simon. 

H.  Gerber. 

Chevalier  &  Henry. 

J.  Bell. 

J.  Bell. 

Clemm. 

Clemm. 

Clemm. 

Leeds. 

Konig. 


Specimen  of  Breast-milk  for  Chemical  Examination. — After  the  third, 
possibly  the  fourth,  day  the  average  healthy  woman  secretes  milk  that 
gradually  becomes  normal  in  quality  and  quantity,  depending  on  her 
general  condition.  It  is  usual  for  an  infant  to  lose  some  weight  during 
its  j&rst  week  of  life,  owing  to  various  physiological  changes,  added  to 
which  is,  no  doubt,  the  deficiency  in  the  quality  and  quantity  of  its  food. 
It  is  a  safe  plan,  and  one  that  I  have  always  urged,  if  at  all  possible, 
to  send  a  specimen  of  breast-milk  to  a  chemist  and  submit  the  same  to 
a  chemical  analysis.  In  some  women  a  specimen  can  be  examined  when  the 
baby  is  one  week  old;  in  others  it  is  better  to  wait  until  the  end  of  two 
weeks.  We  then  would  have  a  proper  working  basis,  and  know  just  how 
much  fat,  carbohydrate  (sugar),  and  albuminoids — including  protein — we 
are  feeding.  Noting  the  weight  of  the  child,  its  sleep,  its  digestion,  color 
and  frequency  of  its  stools,  we  can  easily  see  in  one  week  how  much  the 
infant  has  gained  in  weight,  and  its  general  condition.  To  take  a  specimen, 
it  is  advisable  to  have  all  utensils  absolutely  clean ;  hence  the  following  plan 
would  be  suggested :  Boil  an  ordinary  one  or  two-ounce  bottle  in  water,  to 
which  a  pinch  of  baking  soda  has  been  added,  for  about  one-half  hour. 
Then  place  the  bottle  in  plain  water  and  boil  again  for  a  half-hour.  Then 
turn  the  bottle  upside  down,  and  allow  it  to  drain  and  dry.  In  this  manner 
we  can  completely  sterilize  the  inside  of  the  bottle  and  avoid  contamination. 

Withdraw  a  sample  of  breast-milk  by  means  of  a  breast-pump.  One 
which  has  served  the  author'very  well  is  known  as  the  Florence  breast-pump, 
and  has  a  glass  mouth-piece.  (See  Fig.  33.)  Another  form  is  an  English 
breast-pump,  having  a  rubber  bulb.  Compressing  this  bulb,  we  can  suck 
about  an  ounce  or  more  in  from  five  to  ten  minutes.  This  milk  is  to  be 
poured  into  the  bottle,  and  well  corked,  and  set  in  a  refrigerator,  but 


PLATE  IV 


A  Drop  of  Normal  Breast-milk  from  a  Primipara.      (Original.) 


BREAST-MILK. 


81 


not  on  the  ice.  Milk  will  keep  for  many  hours  in  this  way.  My  plan  has 
been  to  inform  the  chemist  the  day  previous  to  submitting  the  sample,  so 
that  it  can  be  withdrawn  from  the  breast  early  in  the  morning — at  about 
8  A.M. — and  sent  to  the  laboratory  at  once.  The  result  of  the  analysis  can 
be  received  on  the  evening  of  the  same  day  or  on  the  following  day  in  all 
instances.  A  point  worth  noting  is  that  the  very  first  milk  should  not  be 
used,  but  the  infant  should  be  allowed  to  suck  at  the  breast  for  about  two 
minutes  before  pumping  the  sample.  After  this  the  breast-pump  should  be 
applied  for  five  minutes  to  procure  the  middle  milk;  then  the  infant  can 
again  be  put  to  the  breast  to  finish  nursing. 


Fig.  27. — Specimen  of  Breast- 
milk  from  a  Young  Mother,  17  years 
old.  Primipara.  Baby  four  months 
old;  thriving;  gaining  in  weight; 
stools  yellow;  sleeps  well.  Chemical 
examination  :  Fat,  2.60;  sugar,  6.50; 
proteins,  2.54.  Milk  looks  creamy, 
and  the  mammae  are  well  filled. 

(Original.) 


Fig.  28. — Specimen  of  Breast- 
milk,  Illustrating  Very  High  Fat, 
Causing  Gastric  Disturbance.  Baby 
gaining;  vomits  frequently;  stools 
yellowish;  bluish-white  milk;  child 
sleeps  well;  excessive  fats.  Chem- 
ical analysis:  Fat,  5.0;  sugar,  6.50; 
proteins,  1.74;  ash,  0.20.     (Original.) 


Examination  of  Breast-milk. — A  method  which  can  be  employed  in 
general  practice  is  recommended  by  Friedmann  (Deut.  med.  Woch.,  Jan. 
23,  1902).  It  is  more  easily  done  than  a  chemical  analysis,  and  serves 
an  equal  purpose.  It  consists  of  determining  by  microscopical  examination 
the  number  and  character  of  the  milk  corpuscles.  It  is  an  advantage  first 
to  become  familiar  with  the  normal  conditions  by  repeated  examinations 
of  the  milk  from  healthy  mothers,  those  whose  children  are  well  and  show 
no  sign  of  rickets  or  glandular  enlargements.  The  milk  corpuscles  can 
be  divided  as  to  size  into  three  groups,  large,  small,  and  intermediate,  of 
which  the  latter  are  most  numerous.  The  small  ones  are  also  found  in 
almost  equal  numbers,,  but  the  large  ones  are  comparatively  scarce,  a  mag- 
nification of  400  diameters  showing  only  about  10-20  in  the  field.    If  these 


82  NUTRITION. 

be  more  numerous  the  milk  is  found  to  be  too  fatty  and  more  difficult  to 
digest.  A  preponderance  of  the  small  corpuscles  usually  means  a  chronic 
dyspepsia  for  the  nursing  infant.  An  accurate  count  can  be  made  with 
some  form  of  blood-counting  apparatus,  but  the  latter  is  not  essential.  The 
proximity  of  the  corpuscles  to  each  other  also  serves  as  a  guide  to  the  grade 
of  the  milk,  the  more  sparsely  distributed  the  globules  and  the  greater  the 
number  of  the  small  ones,  the  poorer  the  quality  of  the  milk.  The  method 
also  serves  to  differentiate  the  character  of  the  milk  from  the  two  breasts. 
In  the  selection  of  wet-nurses  it  is  obviously  useful. 

Reaction  of  Human  Milk. — Bordet  has  called  attention  to  the  precipi- 
tation of  the  albuminoids  in  milk  when  it  is  added  to  the  serum  in  animals 
which  have  been  previously  injected  with  milk  from  the  same  source. 
Schlossmann  found,  further,  that  the  fluid  from  a  hydrocele  on  a  breast 
child  was  also  able  to  precipitate  the  albuminoids  in  human,  but  not  in  cows' 
milk.  According  to  Moro,  if  a  few  drops  of  human  milk  are  added  to  a 
few  cubic  centimeters  of  fluid  from  a  hydrocele,  in  a  very  few  minutes  the 
hydrocele  fluid  coagulates  into  a  solid  mass.  This  reaction  does  not  occur 
with  cows'  or  goats'  milk.  The  hydrocele  fluid  evidently  contains  fibrinogen, 
and  the  milk,  fibrin  ferment.  The  combination  of  the  two  induces  the 
coagulation.  It  occurs  even  with  minute  quantities  of  the  milk;  all  the 
serum  in  contact  with  the  milk  coagulates  around  it.  The  same  reaction 
occurs  when  human  serum  is  added  instead  of  the  milk,  but  much  less  pro- 
nounced and  much  slower,  and  the  same  difference  is  observed  when  the 
human  milk  is  boiled  or  long  heated.  Particles  of  coagulated  ox  blood  also 
induced  a  slow  and  partial  coagulation. 

It  seems  to  be  established  that  the  mucous  membrane  of  the  stomach 
secretes  an  enzyme  or  fat-splitting  ferment.  Ibrahim  discovered  a  lipolytic 
ferment  in  the  stomach  of  a  nursling. 

Diastatic  Enzyme  in  Human  Milk  and  in  the  Stools  of  Nurslings. — 
Dr.  Ernest  Moro  reports  from  Escherich's  clinic,  in  Graz,  that : — 

First. — Human  milk  contains,  normally,  an  intensive,  saccharifying 
enzyme,  which  is  not  found  in  cows'  milk. 

Second.- — This  enzyme  is  found  in  the  stool  of  breast-fed  children  and 
signifies  a  more  pronounced  diastatic  action  of  the  same. 

Third. — This  diastatic  enzyme  is  secreted  by  the  glands  of  the  intestine. 
Parts  of  the  same  can  be  found  in  the  pancreatic  juice  of  the  new-born. 

Fourth. — The  intestinal  contents  and  faeces  of  nurslings  contain  at  birth, 
as  a  rule,  a  diastatic  enzyme,  which  increases  in  the  first  few  weeks  of  life. 

Immunity  Conferred  by  Breast-milk. — The  nursing  infant  is  usually 
exempt  from  infectious  diseases,  although  we  do  find  an  occasional  case  of 
infection  in  a  breast-fed  infant.    Such  is  the  exception  rather  than  the  rule. 

Piead  chapter  on  "Measles"  for  cases  of  immunity  seen  by  me  in  the 
Riverside  Hospital. 


]5|{KAST -MILK. 


83 


There  seems  to  be  an  ininmnity  conveyed  to  the  infant  through  its 
mother's  milk.  These  substances  which  convey  immunity  have  been 
studied  by  Brieger  and  Ehrlich.  During  epidemics  nursing  infants  rarely 
succumb  to  infections.  The  following  case  will  illustrate  the  manner  in 
Avliich  immunity  can  be  "conveyed"  through  the  milk: — 

A  woman  .suffering  with  diphtheria  was  four  montlis  pregnant  at  tlie  time  of 
infection.  She  was  injected  with  2000  units  of  antitoxin  and  recovered  in  about 
six  days.  Several  months  after  the  birth  of  lier  child,  an  older  child  in  the  family 
was  attacked  with  diphtheria,  which  required  several  injections  of  antitoxin,  also 
intubation,  to  relieve  a  severe  form  of  croup.  Although  the  new-born  infant  was 
in  the  same  room  it  did  not  show  any  signs  of  the  disease.  This  was  most  likely  due 
to  the  immunity  conferred  upon  the  child  by  its  mother  through  her  breast-milk. 

To  Preserve  Human  Mlilk. — Human  milk  collected  from  various 
women  may  be  preserved  for  many  weeks  if  treated  in  the  following 
manner:  Test  the  milk  with  litmus  paper  to  be  sure  that  it  is  ampho- 
teric or  alkaline.  If  it  is  not  alkaline,  add  a  few  drops  of  bi-carbonate 
of  soda  solution.  Then  add  0.2  cubic  centimeters  of  a  concentrated  30 
per  cent,  perhydrol  solution.  This  quantity  of  perhydrol  is  sufficient 
for  400  cubic  centimeters  milk.  The  milk  is  then  thoroughly  shaken  so 
that  the  perhydrol  produces  its  chemical  effect.  On  close  inspection 
small  bubbles  can  be  seen  in  the  milk.  Lastly  the  milk  is  heated  for  ten 
minutes  in  a  water  bath  to  120  degrees  F.  Milk  so  treated  by  Dr. 
Meierhoffer  was  tasted  by  me  in  the  Children's  Wards  of  Dr.  Paul  Moser, 
in  Vienna,  and  seemed  perfectly  fresh  although  it  was  one  month  old. 

Table  Xo.  13.; — Five  Analyses  of  Human  Breast-milk.^ 


Case 

Ko.  1. 

Per  cent. 

Case 

No.  2. 

Per  cent. 

Case 

No  3. 

Per  cent. 

Case 

No.  4. 

Per  cent. 

Case 

No.  5. 

Per  cent. 

"Water     

86.2 
1.7 
6.5 
5.4 
0.2 

89.0 
1.3 
5.8 
2.5 
0.3 

87.0 
1.6 
6.6 
3.8 
0.2 

88.6 
1.1 
6.7 
2.7 

88  1 

Proteins 

1  1 

Lactose 

6  2 

Fab 

4  1 

Salts 

Case  I  of  Table  13  showed  symptoms  of  gastric  disturbance,  chiefly 
vomiting,  caused  by  "feeding  high  fat.''  The  mother  of  the  infant  believed 
that  by  eating  frequently  and  of  very  rich  food,  she  would  benefit  her  bab}', 
thus  her  millv  showed  5.1:  per  cent,  of  fat. 

.  By  reducing  her  diet,  excluding  meat  and  too  many  eggs,  discontinuing 
alcoholic  and  malted  l)eveTages,  her  milk  improved,  the  fat  being  decreased. 
Exercise,  such  as  walking,  was  ordered  for  the  mother. 


ticut. 


^Analyses  made  by  Lafayette  B.  :\rondol,  Yale  L'niversity,  Xcw  Haven,  Connec- 


84 


NUTRITION. 


Table  No.  14. — Table  ShovAng  Analyses  of  a  Normal,  a  Poor, 
an  Over-rich,  and  a  Bad  Human  Breast-mAlk?- 


Normal  Milk. 
Exercise  and 
Good  Food. 

Poor  Milk. 

Poor  Food. 

(Low  Fat. 

High  Protein.) 

Over-rich  Milk. 

Rich  Food. 

No  Exercise. 
(Excess  of  Fat ) 

Bad  Milk. 

Wet-nurse 
Menstruating. 

(Low  Fat. 
Low  Protein.) 

Fat 

4.00 
6.50 
1.75 
.19* 

1.00 

6.50 

2.36 

.24 

6.59 

6.69 

1.16 

.19 

.65 

Sugar  

6.50 

Protein    

1.12 

Mineral  Matter . . . 

.11 

Total  Solids 

Water   

12.44 
87.56 

10.10 
89.90 

14.63 

85.37 

8.38 
91.62 

Total    

100.00 

100.00 

100.00 

100.00 

Specimens  examined  by  Mr.  Bailey,  chemist  of  the  Pediatrics  Laboratory. 

Bkeast-feeding. 

Ihiring  the  first  and  second  months  feed  every  three  hours,  but  never 
oftener. 

During  the  day  awaken  the  child  every  three  hours,  to  be  nursed;  but 
during  the  night  let  the  child  rest  as  long  as  it  appears  satisfied.  This 
rule  applies  to  healthy  children  only.  In  sickness  special  rules  for  feeding 
are  required.  If  the  child  thrives  and  gains  in  weight,  then  it  is  advisable 
and  in  the  interest  of  the  mother  and  child  to  have  an  interval  of  from  seven 
to  eight  hours  at  night;  thus  Bouchut  advises  the  last  feeding  between  10  and 
11  P.M.,  and  the  first  feeding  at  6  a.m.  If  the  child  is  restless,  then  turn 
it  from  side  to  side ;  thus,  changing  its  position  and  giving  it  one  or  two  tea- 
spoonfuls  of  boiled  water  will  frequently  satisfy  it  and  prolong  its  sleep. 

Table  No.  15. — Time  for  Feeding. 


From  Birth  to 
3  Months  Old. 

3to  8  Months  Old. 

8  Months  Until 
1  Year  Old. 

6.00  A.  M. 

9.00  A.  M. 
12.00  Noon 

3.00  P.  M. 

6.00  P.  M. 

9.00  P.  M. 
12.00  Midnight 

6.00  P.  M. 
9.30  A.  M. 
1.00  P.  M. 
4.30  P.  M. 
8.00  P.  M. 
12.00  Midnight 

6.00  A.  M. 
10.00  A.  M. 

2.00  P.  M. 

6.00  P.  M. 
10.00  P.  M. 

^  I  am  indebted  to  the  chemist  of  the  Walker-Gordon  Laboratory  for  a  series  of 
chemical  analyses  herein  reported. 


MATERNAL  FEEDING.  85 

The  first  three  or  four  days  require  special  feeding  methods.  On  the 
day  of  the  birth,  the  exhaustion  of  Jhe  mother  and  presence  of  colostrum, 
besides  the  normal  deficient  quantity  of  food  in  the  breast,  demand  large 
intervals  of  rest.  Thus  for  the  first  three  days  (unless  the  milk-supply  is 
profuse)  putting  the  infant  to  the  breast  once  in  six  hours  is  sufficient;  if, 
however,  the  supply  of  milk  is  ample,  then  we  can  follow  the  table  given 
above  and  nurse  the  infant  every  three  hours. 

Maternal  Feeding. 

The  feeding  of  infants  will  always  be  a  live  question.  It  is  simplifiea 
^rhen  maternal  means  are  used.  The  plea,  therefore,  to  resort  to  human  milk 
i  ceding  means  not  only  to  obviate  the  difficulties  of  home  modification  of 
cows'  milk  and  the  dangers  of  contamination,  but  it  also  means  that  we 
give  the  infant  the  proper  start  in  life.  The  foundation  must  be  strong, 
and  such  foundation  depends  on  the  growth  and  development  of  the  organs, 
due  to  proper  metabolism  of  fat,  carbohydrate,  and  especially  of  the  protein. 
B'uman  milk  contains  an  assimilable  form  of  iron  besides  a  given  quantity 
of  salts  to  be  utilized  in  the  growth  of  bone  and  teeth ;  it  is  thig  lack  of  iron 
in  cows'  milk  that  renders  it  less  nutritious. 

The  virtues  of  human  milk  have  been  extolled  from  many  infectious 
hospitals,  where  it  is  found  that  there  is  more  vitality  in  an  infant  that 
nurses  the  human  breast  than  in  the  infant  reared  by  artificial  means.  The 
susceptibility  to  infections  is  far  less  in  the  infant  nursed  at  the  human 
breast  than  in  the  infant  brought  up  by  artificial  means.  What  applies 
in  infancy  applies  equally  well  in  later  life  and  there  is  no  question  in  my 
mind  that  the  breast-fed  infant,  being  the  stronger,  will  also  be  able  to  with- 
stand the  infection  of  tuberculosis  in  later  life.  Our  plea  shonld,  therefore, 
be  primarily  for  the  education  of  the  mother,  especially  so  for  the  mother 
who  believes  the  modern  fad  of  artificial  feeding  is  equally  as  good  as  the 
natural  method. 

*  Human  milk  contains  a  diastasic  ferment.  Peroxydase  is  found  in 
cows'  milk.  Many  cases  require  but  several  months  for  a  proper  start  in  life. 
The  most  critical  period  of  an  infant's  life  is  the  first  three  months;  hence 
it  is  imperative  to  start  right. 

An  infant  is  not  born  with  a  diseased  stomach :  it  is  born  with  a  healthy 
stomach,  with  normal  digestion,  and  with  power  to  assimilate  almost  any 
kind  of  food.  Any  one  who  will  study  the  digestive  conditions  of  the  first 
six  or  eight  weeks  of  infantile  life,  will  find  that  almost  every  type  of  food 
will  be  assimilated.  If  an  excess  of  fat  or  protein,  is  ordered  the  same  will 
not  show  marked  systemic  disturbance  until  after  the  first  six  or  eight 
weeks  of  life.  Feeding  formula  which  would  give  rise  to  marked  gastric 
disturbance  during  the  third  and  fourth  months  are  frequently  well  borne 


86  NUTRITION. 

and  apparently  digested  during  the  first  month  of  life.  This  is  because 
we  are  dealing  with  a  healthy  gastric  ♦mucosa  plus  normal  secretions,  and 
because  pathological  conditions  have  not  yet  developed.  This  accounts  for 
the  tolerance  of  high  fats  and  high  protein  in  early  infancy. 

Casein  is  a  nucleoalbumin  in  a  neutral  combination  with  lime.  Such 
casein  will  be  precipitated  on  the  addition  of  acid.  It  is  not  dissolved  in 
milk,  but  exists  therein  in  a  colloid  form.  In  addition  to  casein  we  have 
lactalbumin,  which  corresponds  to  serum-albumin.  We  also  have  lacto- 
globulin ;  both  are  also  present  in  colostrum. 

The  albumin  of  milk  if  injected  into  a  rabbit  produces  a  serum  which 
can  give  us  the  Bordet  reaction.  Alexins  and  antitoxins,  in  addition  to  sub- 
stances contained  in  the  internal  secretions,  agglutinins,  complements,  are 
found  in  human  milk  and  transferred  thereto  by  the  serum.  According 
to  Ehrlich,  these  substances  give  marked  resistance  and  a  distinct  passive 
immunity  to  the  infant.  During  the  last  few  years  a  study  of  the  physio- 
logical requirements  of  the  infant  has  demonstrated  the  fact  that  our  feeding 
rules  and  feeding  intervals  have  been  wrong,  that  the  tendency  to  overfeed 
exists,  and  that  the  interval  for  proper  assimilation  between  meals  is  too 
small ;  hence  we  must  change  our  methods  to  give  the  infantile  stomach  less 
work  and  at  the  same  time  sufficient  food  for  its  development. 

An  infant  should  nurse  at  birth  seven  times  in  twenty-four  hours,  or 
once  every  three  hours.  At  one  month  the  interval  of  three  hours  should  be 
increased  to  three  and  one-hal:£  hours ;  thus,  no  more  than  five  feedings  by 
day  and  no  feedings  at  night  should  be  given.  In  special  cases  the  infant 
may  require  feeding  every  two  hours,  but  bear  in  mind  that  less  frequent 
feedings  stimulate  a  better  flow  of  milk,  give  the  infant  a  longer  interval  for 
digestion  and  thus  an  increased  appetite. 

When  scanty  supply  of  human  milk  exists,  then  mixed  feeding,  alternate 
breast  and  bottle,  may  be  given,  but  it  is  important  to  look  upon  the  human 
milk  as  the  most  precious  food,  and  every  drop  to  be  valued  far  more  than 
the  cows'  milk  that  we  use  to  supply  the  deficiency  of  the  human  breast.  A 
close  study  of  infantile  stools  during  maternal  feeding  has  shown  that  there 
are  frequently  tendencies  to  either  constipation  or  the  reverse,  loose  or  green- 
ish stools.  Neither  of  the  above  conditions  should  be  regarded  as  serious 
factors  and  by  no  means  should  we  look  upon  the  human  breast  with  dis- 
favor even  though  the  stools  do  not  correspond  to  that  desired  yellowish, 
pasty  consistency.  So  many  factors  are  at  play,  alkalinity  of  the  intestine, 
or  acidity  of  the  intestine,  likewise  chemical  alterations  in  the  milk,  and 
atmospheric  or  thermic  influences  inhibit  the  proper  function  of  the  glands 
so  that  the  intestinal  ferment  may  or  may  not  perform  its  function.  Such 
condiiions  must  be  borne  in  mind  before  a  final  conclusion  to  discard  a  human 
breast  of  milk  is  reached. 


BREAST-FEEDING.  87 

Another  point,  and  one  frequently  submitted,  is,  shall  a  woman  continue 
to  nurse  her  infant  if  she  menstruates  ?  to  which  one  should  reply  that  the 
condition  of  the  infant  is  not  afl'ected  by  the  presence  of  the  function  of 
menstruation,  and  human  milk  may  be  utilized  as  if  the  same  were  absent. 
The  bacterial  content  of  the  intestine  of  an  infant  nursed  at  the  human 
breast  has  far  less  pathogenic  bacteria  than  the  infant  fed  on  cows'  milk. 

Suggestions  for  Breast-feeding. 

The  mother  or  wet-nurse  should  always  sit  upright,  be  it  at  night  or 
during  the  day,  while  nursing  the  infant. 

Danger  of  Suffocation. — A  great  many  cases  are  on  record  where  the 
mother  or  wet-nurse  has  fallen  asleep  while  nursing  and  smothered  the  in- 
fant. For  this  reason  it  is  important  that  the  infant  should  sleep  in  its 
own  crib  or  bed,  and  should  never  sleep  with  the  mother  or  nurse. 

Shall  an  Infant  Receive  but  One  or  Both  Breasts  for  One  Meal? — 
This  depends  on  the  infant's  appetite.  Some  infants  appear  satisfied 
after  nursing  from  one  breast,  and  will  let  go  of  the  nipple  and  fall  asleep. 
Lightly  tapping  the  cheeks  of  the  infant  will  awaken  it,  or  the  withdrawal 
of  the  nipple  from  the  infant's  mouth  will  frequently  arouse  it  to  continue 
nursing.  If,  however,  the  infant  will  not  renew  its  nursing,  and  still  con- 
tinues to  sleep,  and  if  the  infant  has  nursed  steadily  for  ten  minutes,  then 
the  sleep  should  not  be  disturbed. 

Length  of  Time  for  Nursing. — A  good  plan  is  to  note  the  time  when 
the  nursing  act  commences  and  stops.  No  infant  should  nurse  longer  than 
twenty  minutes,  whereas  frequently  ten  or  fifteen  minutes  will  suffice.  If 
an  infant  nurses  more  than  twenty  minutes,  say  thirty  or  forty  minutes, 
then  we  may  be  sure  that  the  breast-milk  is  deficient  in  quantity  and  a 
specimen  should  at  once  be  submitted  for  a  proper  chemical  examination. 

Scanty  Beeast-milk  Eequieing  Mixed  Feeding. 

When  there  is  a  deficiency  in  the  quantity  of  breast-milk,  but  the  quality 
is  good,  then  it  is  advisable  to  feed  the  infant  alternately  with  breast-milk 
and  bottle-milk.  At  the  same  time  it  is  advisable  to  direct  attention  to  the 
mother's  general  condition,  and  see  if  we  cannot  tone  her  up,  and  thus  im- 
prove both  quality  and  quantity  of  her  milk.  Frequently  a  subnormal  or  an 
ansmic  condition  requires  iron.  A  day's  outing  to  the  country  or  seashore, 
with  moderate  exercise,  will  stimulate  and  increase  the  flow  of  milk.  Every 
drop  of  breast-milk  is  so  precious  that  no  infant  should  be  deprived  of  it, 
and  wise  is  the  physician  who  will  insist  upon  giving  all  breast-milk.  When 
there  is  deficient  lactation,  supply  the  deficiency  by  giving  a  properly  diluted 
milk  or  cream  mixture,  adapted  for  the  age  and  weight  of  the  infant. 


38  NUTRITION. 

To  Increase  the  Quantity  of  Breast-milk. — Some  of  the  galactagogues 
have  given  me  satisfaction,  in  addition  to  a  nutritious  diet,  such  as  meat, 
milk,  and  eggs.  A  preparation  on  the  market  known  as  Nutrolactis^  has 
proven  a  most  valuable  galactagogue.  It  is  given  in  tablespoonful  doses 
three  times  a  day.  This  will  not  only  stimulate  the  quantity,  but  also  the 
quality,  of  the  milk.  Grandin  and  Jarman,  in  their  text-book  on  "Obstet- 
rics," recommend  the  strong  infusion  of  galega  officinalis  when  the  flow  of 
milk  is  scant.  This  is  to  be  ordered  in  tablespoonful  doses  three  or  four 
times  a  day.  Malt  tropon,  one  teaspoonful  three  times  a  day,  after  meals 
will  stimulate  the  flow  of  milk. 

Somatose  in  Cases  of  Deficient  Lactation. — "A  primipara  who  secreted  only  a 
limited  amount  of  colostrum,  and  kept  that  up  so  that  the  child  was  crying  from 
hunger  and  had  to  be  artificially  fed,  was  put  upon  somatose,  4  teaspoonfuls  a  day, 
and  in  three  days  the  patient  secreted  a  sufficient  quantity  and  quality  of  milk  to 
satisfy  the  child,  which  increased  one-fourth  of  a  pound  regularly  each  week.  It 
seemed  difficult  to  induce  the  mammary  glands  to  perform  their  proper  function; 
but  when  somatose  was  given  there  was  a  normal  supply  of  milk,  and  the  child  was 
properly  nourished  without  artificial  feeding." 

Do  Drugs  Taken  by  a  Nursing  Woman  Affect  the  Baby  ? 

Physiological  experiments  have  frequently  demonstrated  the  fact  that 
a  great  many  drugs  can  be  given  to  an  infant  through  the  milk ;  thus,  opium 
and  morphine  and  narcotics  in  general  do  affect  the  infant,  when  taken  by 
the  mother,  Baginsky  calls  attention  to  this  fact  in  his  text-book  on  "Dis- 
eases of  Children":  "Alcohol,  when  taken  by  the  mother,  is  transmitted 
through  the  milk,  but  not  in  very  large  quantities.  The  following  is  a  list 
of  drugs  which  have  been  found  in  milk :  The  purgative  principles  of  rhu- 
barb, senna,  and  castor-oil;  the  metals,  antimony,  arsenic,  iodine,  bismuth, 
lead,  iron,  mercury;  the  volatile  oils,  like  copaiba,  garlic,  and  turpentine; 
also  salicylic  acid,  and  the  iodides  and  bromides."  Do  not  give  cocaine, 
chloral,  atropine,  or  hyoscyamus.  Care  is  to  be  used  with  the  following: 
Digitalis,  antipyrin,  and  ergot.  An  unpleasant  flavor  can  be  imparted  to 
the  breast-milk  by  the  mother  or  wet-nurse  eating  onions,  turnips,  cauli- 
flower, or  cabbage. 

Disturbances  During  Breast-feeding. 

Quite  frequently  we  meet  with  gastro-intestinal  disorders  in  infants 
that  are  wholly  breast-fed.  These  disturbances  are  due  to  (a)  insufficient 
exercise;  (&)  faulty  diet;  (c)  extreme  nervous  irritability;  (d)  menstrua- 
tion while  nursing;  (e)  physiological  changes  in  the  woman,  causing  an 
improper  ratio  of  ingredients.  Some  of  the  causes  just  mentioned  can  easily 
be  remedied.  On  the  other  hand,  a  very  nervous  woman,  whose  anxiety  keeps 
her  constantly  fretting  during  the  day  and  awake  at  night,  will  hardly  be 


^  Sold  in  all  drug  stores. 


BREAST-FEEDING.  89 

adapted  for  breast-feeding,  and  the  sooner  the  infant  is  removed  from  such 
a  breast,  the  better  for  the  infant. 

The  following  cases  will  illustrate  the  above  conditions: — 

An  infant  was  nursed  by  its  mother.  The  mother  was  extremely  nervous, 
fretful,  did  not  sleep  at  night,  and  nursed  her  child  too  often. 

Tlie  infant  suffered  with  colic,  had  greenish,  cheesy  stools,  and  did  not  gain  in 
weight.  Had  indigestion  and  all  evidence  of  intestinal  colic.  The  case  was  seen 
by  me  through  the  courtesy  of  Dr.  A.  A.  Richardson,  of  New  York  City.  The  physi- 
cian assured  me  that  the  mother  would  not  leave  her  home,  and  that  she  had  had 
no  outdoor  exercise,  no  fresh  air,  and  nothing  but  the  constant  worry  of  a  sick,  crying 
baby  which  she  nursed  as  best  she  could.  A  chemical  examination  of  the  breast- 
milk  showed  the  following: — 

Fat 1.20 

Sugar 6.50 

Protein    1.70 

Ash    0.18 

Total  solids 9.58 

Under  the  influence  of  exercise  and  careful  diet  the  fat  was  increased.  In  this 
case  we  alternated  breast  and  bottle  feeding,  and  gave  the  child  mixed  feeding.  A 
formula  of  2  per  cent,  fat,  5  per  cent,  sugar,  and  0.75  per  cent,  protein  was  pre- 
scribed at  the  Walker-Gordon  Laboratory. 

An  infant  one  month  old  was  seen  by  me  in  the  family  of  Dr.  J.  Grosner,  of 
this  city.  The  infant  had  been  vomiting,  had  had  colic,  and  was  very  restless.  The 
mother  was  very  nervous,  but  had  an  abundance  of  milk.  From  the  history  I 
learned  that  the  child  had  had  an  explosive  vomit,  the  food  coming.out,  besides  large 
quantities  of  gas.  There  were  five  to  seven  stools  in  twenty-four  hours.  The  bowels 
moved  at  each  nursing.     The  chemical  examination  of  the  breast-milk  showed: — 

Fat 4.00 

Sugar     6.50 

Protein    3.05 

Ash    0.30 

Total  solids    .' 13.85 

From  this  examination  it  can  be  seen  that  for  a  baby  six  months  old 
there  was  an  excess  of  fat  and  also  a  very  high  percentage  of  protein. 

An  infant  one  to  two  months  old  requires  2  per  cent,  of  fat.  ISTote  also 
a  normal  infant  receives  between  1  and  l^/^  per  cent,  of  protein,  while  this 
child  received  more  than  3  per  cent,  of  protein.  There  being  a  profuse 
secretion  of  milk,  the  child  received  far  more  than  it  could  digest  in  both 
quality  and  quantity.  The  feeding  interval  was  lengthened,  and  the  time 
of  nursing  was  reduced  to  five  minutes,  whereas  until  the  appearance  of 
vomiting  the  child  nursed  twenty  minutes.  An  ounce  of  sterilized  water  was 
ordered  immediately  after  each  nursing,  hoping  to  thus  dilute  the  milk. 
This  method  proved  successful. 


90 


NUTRITION. 


A  Case  of  Prolonged  Lactation,  Showing  Deficiency  of  Nutriment. — ^A  cMld. 
about  1  year  old,  was  brought  to  me  with  the  following  history:  It  has  no  teeth. 
Can  neither  stand  nor  walk.     It  is  colicky.     Does  not  sleep  well.     Does  not  gain 


Fig.  29. — Showing  a  Drop  of  Milk  under  the  Microscope.  Note  the 
poor  character  of  this  emulsion,  the  uneven  fat-globules,  and  their  irregular 
size  and  distribution.  The  infant  nursed  with  the  above  milk  was  rachitic 
and  colicky.  Although  15  months  old,  no  tooth  had  appeared.  The  mother 
of  the  infant  states  that  she  menstruated  every  twenty-one  or  twenty-two 
days  since  her  infant  was  born — during  this  present  nursing  period. 
(Original.) 


Fig.  30. — This  Drop  of  Breast-milk  is  from  a  very  Anemic  Woman. 
The  child  was  extremely  emaciated,  had  greenish  stools  and  colic,  and  was 
always  crying.  Note  the  uneven  character  of  above  emulsion,  when  com- 
pared with  Plate  VII.  The  infant  was  poorly  nourished;  had  rickets  and 
marked  cranio-tabes.  Mixed  feeding  was  resorted  to,  with  decided  improve- 
ment.    (Original.) 


weight.  The  child  was  nursed  every  three  or  four  hours.  The  mother  was  very 
nervous,  and  menstruated  almost  every  month  during  lactation.  The  chemical  anal- 
ysis of  the  milk  gave: — 

Fat 1.22 

Sugar     7.07 

Protein   0.98 

J 


BREAST-FEEDING.  91 

It  was  very  evident  tliat  this  baby  was  receiving  poor  milk,  very  low  fat,  and 
deficient  protein.  The  infant  was  weaned,  artificial  feeding  was  prescribed,  and  the 
infant  immediately  showed  a  gain  in  weight.     The  symptoms  of  colic  disappeared. 

Illustration,  of  Prolonged  Lactation  Without  Apparent  Harmful  Effects. — An 
infant  fifteen  months  old  was  brought  to  me  for  the  relief  of  constipation.  It  had 
ten  teeth,  was  able  to  stand  and  walk,  and  was  beginning  to  talk.  The  infant  was 
still  breast-fed.     The  analysis  of  the  milk  gave  the  following:  — 

Fat   2.86 

Sugar  6.78 

Protein 1.76 


Fig.  31.— Holt's  Milk  Test  Set,  for  Testing  Human  Milk. 

The  infant's  weight  in  this  case  was  normal,  and  I  must  regard  this 
prolonged  lactation,  showing  such  good  results,  as  an  exception  rather  than 
a  rule. 

Additional  Foods  During  the  Nursing  Period, 

Between  the  sixth  and  eighth  months,  if  the  infant  is  thriving  and 
gaining  in  weight,  cereal  feedings  should  be  added.  A  small  saucer  of 
farina,  or  cream  of  wheat  steamed  with  water,  for  two  hours,  and  served 
with  skimmed  milk  and  a  small  quantity  of  sugar,  should  be  given  before 
the  10  A.M.  feeding.  This  cereal  feeding  may  be  given  daily  if  there  are 
no  symptoms  of  starch  indigestion,  such  as  flatulence,  colic,  or  distended 
abdomen,  noted.  At  twelve  months  the  yolk  of  a  raw  egg  may  be  added  to 
the  cereal.  Additional  foods  which  may  be  given  to  an  infant  after  the  teeth 
erupt,  or  between  the  seventh  and  twelfth  months,  are:  Two  ounces  of 
expressed  beef  juice  over  a  small  saucer  of  steamed  rice;  a  piece  of  rusk  or 


93  NUTRITION. 

biscuit  after  the  bottle.     A  coddled  egg  at  noon  may  be  tried  when  the 
infant  is  one  year  old,  and  if  it  agrees,  it  may  be  ordered  every  other  day. 

The  Management  oe  the  Nipples  Before  the  Baby  is  Born. 

It  is  very  important  during  the  last  few  months  of  pregnancy  to  devote 
considerable  time  and  attention  to  the  condition  of  the  nipples.  If  these 
be  found  long  and  round,  well  projecting,  then  it  is  advisable  to  try  to  harden 
them,  because  the  irritation  from  the  child  will  cause  considerable,  trouble 
unless  we  seek  to  prevent  this. 

Oni,  in  treating  the  question  of  sore  nipples,  said  at  the  Medical 
Society,^  that  one  out  of  every  two  nursing  women  was  affected  with 
lesions  of  the  nipples.  The  determining  cause  of  the  fissures  was  macera- 
tion of  the  epiderm  under  the  double  influence  of  the  saliva  of  the  infant 
and  the  milk  which  flowed  during  the  intervals.  The  epiderm  exfoliated 
and  the  derm  exposed  became  excoriated;  the  lesion  thus  produced  became 
infected,  and,  instead  of  healing,  progressed  in  extent.  The  predisposing 
causes  were  short  and  inextensive  nipples  and  want  of  cleanliness.  The 
primiparjE  were  affected  with  fissured  nipples  to  the  extent  of  59  per  cent. 

The  prophylactic  treatment  consisted  in  astringent  lotions  during 
pregnancy,  while  after  delivery  the  nipple  should  be  washed  with  boric 
acid  lotion  before  and  after  suction,  the  application  of  an  antiseptic 
dressing  during  the  intervals  of  nursing.  The  curative  treatment,  to  be 
radical,  consisted  in  the  suspension  of  nursing,  which,  although  excellent 
for  the  mother,  would  be  deplorable  for  the  child.  The  list  of  agents 
employed  against  the  fissure  was  very  lengthy,  indicating  their  uselessness. 

In  summer  cold  water  will  be  found  more  agreeable,  with  a  small  quan- 
tity of  alcohol.  If  the  nipples  are  very  small  and  flat,  and  do  not  protrude 
properl}'-,  then  suction  by  means  of  a  breast-pump,  applied  directly  over  the 
breast,  will  draw  them  out.  In  some  instances  an  ordinary  clay  pipe  which 
has  a  smooth  bowl,  the  bowl  to  be  laid  over  the  nipple  and  the  stem  to  be 
sucked  or  drawn,  is  satisfactory.  This  is  to  be  repeated  every  few  days. 
A  few  minutes  of  drawing  out  will  suffice  until  the  nipples  are  sufficiently 
prominent.  Biedert^  gives  the  following  prescription  for  hardening  the 
nipples : — 

Tannic  acid 1  teaspoonful 

Red  wine   8  ounces 

If  red  wine  is  not  handy,  then  substitute  brandy  in  its  stead.  This  is 
to  be  applied  after  thorough  washing  with  soap  and  water,  and  removing 
crusts,  if  they  are  present. 

Tender  Nipples. — If,  while  nursing,  the  nipples  crack  and  blood  oozes 
from  them,  or  if,  from  irritation  of  the  child's  gums  biting  them,  the  nipple 


^  Paris  Cor.  Med.  Press  and  Circular. 

*  "Kinderernaehrung,"  fourth  edition,   1900,  page  110. 


BREAST-FEEDING. 


93 


is  sore,  then  it  is  a  good  plan  to  allow  the  child  to  nurse  through  a  nipple- 
shield.     (See  Fig.  32.) 


Fig.  32. — ^Nipple-shield  for  Relief  of  Tender  Nipples, 

Nipple-shields  can  be  used  during  the  nursing  act,  and  immediately 
thereafter  the  following  salve  can  be  smeared  on  the  nipples : — 

IJ  Zinc  oxide   1  drachm 

Vaseline  1  ounce 

TREATMENT  OF  TENDER  NIPPLeS  (GARRIGUES). 

IJ  Orthoform   1  drachm 

Lanoline   1  ounce 

M.     Sig.:     Apply. 


Fig.  33. — Breast-pump. 

Breast-pump. 

The  breast-pump  (Figs.  33  and  34)  is  a  valuable  addition  to  the  nur- 
sery. It  should  be  kept  scrupulously  clean  by  immersing  it  in  boiling  water 
containing  a  pinch  of  table-salt.  In  drawing  a  specimen  of  breast-milk  for 
a  chemical  examination  the  breast-pump  is  very  useful.    If  an  infant  is  ill 


94  NUTRITION. 

and  refuses  the  breast — as^  for  example^  if  it  has  rhinitis  or  cold  in  the  head, 
nasal  obstruction,  preventing  it  from  breathing  while  the  nipple  is  in  its 
mouth — it  generally  will  take  the  breast  and  immediately  let  go  of  it  again. 
If  the  breast-pump  is  properly  applied,  and  the  required  quantity  of  milk 
drawn  off,  the  infant  can  be  fed  slowly  with  a  spoon. 

In  a  serious  condition — as,  for  example,  in  a  severe  case  of  pneumonia 
with  loss  of  appetite — the  life  of  the  child  may  depend  on  forced  feeding. 
This  is  described  in  the  section  on  "Gravage."  It  is  very  important  to 
have  the  cup  or  any  other  receptacle  into  which  we  draw  the  breast-milk 
properly  sterilized;  otherwise  the  breast-milk  will  be  infected  in  the  same 
manner  as  is  described  in  detail  in  the  chapters  on  "Cows'  Milk"  and 
"Bottle-feeding." 


Fig.  34. — Breast-pump. 

Massage  oe  the  Bkeast  Dueing  Lactation. 

Caking. — ^The  "caking,"  or  hardening,  of  the  breast  is  not  due  to  cur- 
dling of  the  milk.  This  never  takes  place  within  the  milk-tubes.  ISTeither 
is  it  due  to  the  presence  of  milk,  for  as  a  rule  no  milk  is  formed  until 
nursing  begins,  or  if  any,  but  a  very  small  amount.  The  hardening  of 
the  gland  is  due  to  the  congestion  of  the  blood  and  lymph,  and  therefore 
massage  should  be  directed  to  the  removal  of  these,  and  likewise  should 
be  centrifugal  in  direction,  and  not  aim  to  the  removal  of  the  milk  by  centrip- 
etal stroking.  The  blood-supply  of  the  gland  is  mainly  derived  from  the 
subclavian  and  axillary  arteries ;  the  venous  outflow  and  the  lymph  discharge 
are  by  corresponding  channels,  and  this  is  the  anatomical  basis  for  action. 
The  massage  should  begin  gently  below  the  clavicle  and  in  the  axilla,  and 
gradually  encroach  more  and  more  on  the  mammary  region.  By  this  method 
a  hard  and  painful  breast  is  rendered  lax  and  comfortable  without  the  dis- 
charge of  any  milk.  The  writer  does  not  recommend  this  treatment  where 
there  is  infection  or  true  inflammation,  as  in  mastitis;  in  such  conditions 
rest  is  indicated,  and  nothing  should  be  done  which  will  tend  to  spread  the 
infection.^ 

Tpie  Diet  of  a  Nursing  Moti-ier. 

Immediately  after  the  birth  of  the  child  the  exhausted  condition  of  a 
woman  following  labor  will  certainly  call  for  rest ;  hence  sleep  is  imperative, 
after  which  some  form  of  stimulation  is  required.    This  can  best  be  accom- 


^See   an   elaborate   paper   on   this  subject  by   Bacon   in   American   Journal  of 
Obstetrics. 


JJIKT  OK  A  NrRSIX(;   .Mo'lllKll.  !).-) 

plished  by  giving  at  intervals  of  several  hours  good,  wholesome  food,  as 
chicken  broth  or  beef  broth,  weak  tea,  or  strained  gruel.  It  is  unnecessary 
to  state  that  each  woman's  case  and  her  former  habits  must  be  taken  into 
consideration  in  prescribing  a  diet.  If  labor  has  been  normal,  then  the  nour- 
ishment will  stimulate  the  milk.  If  warm  liquids  are  not  well  l)orne,  then 
cold  di'inks  like  buttermilk,  koumyss,  zoolak,  or  iced  tea  should  be  em- 
ployed. Iced  chanii)agne  will  frequently  do  more  good  to  allay  gastric  irrita- 
bility than  all  medication.  Raw  milk  in  combination  with  seltzer  or  lime- 
water  is  indicated.  In  some  instances  ice-cream  will  aid  nutrition  and  alle- 
viate gastric  irritation.  If  the  pelvic  condition  is  normal,  then  it  is  wise 
not  to  give  solid  food  for  the  first  three  days,  but,  rather,  stimulate  the  milk- 
glands  by  giving  meat  broths,  farinaceous  gruels,  and  l)y  all  means  milk. 
Zwieback  soaked  in  milk  or  in  tea  is  highly  nutritious  and  easily  digested. 
Other  nutritious  foods  are  calfsfoot  jelly  and  chicken  jelly. 

After  the  third  day,  if  the  pelvic  organs  are  normal,  it  is  wise  to  con- 
sider the  action  of  the  bowels.  If  the  l)owels  have  not  moved  by  this  time, 
then  buttermilk  added  to  the  diet  or  stewed  prunes  or  peaches,  baked  apples, 
or  grapes  will  aid  in  establishing  a  movement  of  the  bowels. 

If  the  milk  is  scanty  and  the  bowels  have  not  moved,  then  the  best 
remedy  is  a  large  tablespoonful  of  palatable  castor-oil,  modified  to  suit 
the  taste  by  the  addition  either  of  lemon  juice  or  orange  juice,  or  by  adding 
several  drops  of  the  ordinary  spirits  of  peppermint.  After  the  bowels  have 
been  evacuated  and  the  general  condition  warrants  it,  then  a  diet  consisting 
of  the  following  is  indicated : — 

BREAKFAST,    7   TO    8   A.M. 

Hominy   and  Milk.  Grapes. 

Farina  and  Milk.  Soft-boiled  Eggs. 

Eice  and  Milk.  Poached  Eggs. 

Oatmeal  and  Milk.  Eggs  on  Toast. 

Germea  and  Milk.  Coffee   and   Milk. 

Cream  of  Wheat  and  Milk.  Tea  and  Milk. 
Some  Stewed  Prunes,  Figs,  or      Cocoa  and  j\Iilk. 

Peaches.  Toast  and  Butter. 

Stewed  Apples.  Stale  Bread  (2  days  old),  with 
Oranges.  Butter. 

I  do  not  advise  meat  or  fish  in  the  morning,  unless  the  nursing  mother 
has  always  been  accustomed  to  this  fonu  of  diet. 

LUNCH,   12  TO   1   P.M. 

Some  soup  made  from  meat,  either  veal,  beef,  mutton,  lamb,  or  chicken, 
i-ontaining  also  some  rice,  barley,  farina,  sago,  or  hominy;  it  should  not 
be  highly  seasoned,  and  should  not  be  strained. 


96 


NUTRITION. 


Fish,  boiled  or  fried,  and  all  shell-fish,  particularly  oysters,  are  very 
nutritious  during  the  nursing  period. 

If  the  appetite  warrants  it,  then  a  piece  of  steak  or  chop,  roast  beef, 
chicken  (white  meat  only),  or  raw  chopped  meat,  with  bread  and  butter, 
is  very  nutritious. 

EVENING,  6  TO  7  P.M. 

A  Bowl  of  Oatmeal  Gruel.  Junket. 

Stewed  Oysters.    ^  Cup  of  Tea. 

A  Drink  of  Milk.  Eggs,  if  desired. 

Farina  Pudding.  Meat,  if  in  the  habit  of  eating 

Eice  Pudding.  it  in  the  evening. 

Cornstarch  Pudding. 

For  Thirst. — Cool,  filtered  water,  or  the  alkaline  waters,  like  Seltzer 
and  Apollinaris. 

If  the  milh  is  scanty,  the  flow  can  he  stimulated  hy  drinhing  a  cup  of 
hot  broth,  made  from  beef,  chicTcen  or  veal,  lamb  or  mutton,  several  minutes 
before  putting  the  child  to  the  breast. 

Alcoholic  DrinTcs. — If  the  woman  is  in  the  habit  of  drinking  wine  or 
beer,  then  it  is  unwise  to  discontinue  the  use  of  alcoholics  in  moderate 
quantities  while  she  is  nursing.  I  have  seen  a  great  many  women  whose 
flow  of  milk  was  scant  who  immediately  secreted  an  abundance  of  milk 
after  partaking  of  a  glass  of  beer,  or  ale,  or  porter  with  their  meals  for  sev- 
eral days.  Beer  has  a  decided  laxative  effect,  and  this  in  itself  is  rather  an 
advantage  for  those  nursing  mothers  having  a  tendency  to  constipation.  So 
my  rule,  therefore,  would  be  to  insist  on  abstinence  from  wine  and  beer 
unless  the  patient  has  been  in  the  habit  of  taking  it  formerly. 

FOODS  TO  BE  AVOIDED  BY  A  NURSING  WOMAN. 

Onions.  Ethereal  Oils. 

Garlic.  Butter  and  Fat  moderately. 

Cabbage.  Candies  and  too  much  Sweets. 

Powerful  Salts  (Rochelle,  Glau-  Large  quantities  of  Potatoes, 
her,  Epsom). 

Inability  of  Mothers  to  Nurse  their  Children. 

It  is  surprising  to  note  the  gradual  disappearance  of  the  healthy,  robust 
American  mother  who  can  perform  the  duty  of  nursing  her  infant.  The 
following  tal)le  will  give  a  fair  illustration  of  the  conditions  as  they  exist  in 
New  York  City  to-day : — 


WET-NURSE.  97 

Table  No.  16. — A  study  of  1000  Mothers  and  their  ability  to  nurse. 


Mothers. 

Condition 

of 
Mother. 

Able  to  Nurse 

9  Months  to 

1  Year. 

Able  to  Nurse 
4  Days  to 
2  Mouths. 

Primiparas. 

Multiparas. 

500^ 

Living   in    Tene- 
ment Houses. 

Very  Poor. 

450^ 

50 

210 

290 

500 

Living  in 

Healthful 

Portions   of 

the  City. 
Prosperous. 

84 

150 

305 

195 

According  to  the  above  statistics,  90  per  cent,  of  the  poor  mothers  are 
able  to  nurse  their  children,  while  only  17  per  cent,  of  the  rich  mothers 
are  able  to  perform  the  same  duty. 


Wet-nurse. 

Two  important  points  are  necessary:  First,  the  presence  of  suitable 
milk ;  second,  the  absence  of  a  constitutional  taint^  or  acute  severe  illness. 

What  to  Examine. — First,  the  breasts  for  the  quantity  of  milk  present. 
The  breast  should  be  gently  but  firmly  held  at  some  distance  from  the 
nipple;  thus  we  can  learn  by  palpation  regarding  the  parenchyma  of  the 
glands.  Also  the  quantity  of  milk,  which,  if  expressed  continuously  about 
twenty  to  thirty  seconds,  should  flow  in  several  streams. 

Stagnant  milk  always  shows  sensitiveness  on  pressure.  The  statement 
of  a  wet-nurse  tliat  her  "milk  is  deficient  in  quantity"  can  be  determined  by 
subjecting  her  to  careful  observation  for  several  hours.  After  this  time  the 
milk  in  the  breasts  should  be  expressed  and  the  quantity  determined. 

The  ease  with  which  milk  can  be  expressed  by  palpation  is  an  impor- 
tant factor  to  note.  If  the  milk  flows  with  great  difficulty,  and  requires 
considerable  massage  or  pumping,  then  such  a  nurse  is  totally  unfit  to  nurse 
atrophic,  marasmic,  or  prematurely  born  babies. 

Weak  or  marasmic  children  require  a  wet-nurse  having  a  plentiful 
supply  of  milk,  so  that  the  slightest  effort  while  nursing  will  result  in 
a  liberal  flow  of  milk. 


^  Thirty-five,  or  7  per  cent.,  of  these  mothers  suffered  from  puerperal  disease, 
such  as  septicaemia,  mastitis,  and  kindred  affections;  hence,  they  were  ordered  by 
their  physicians  not  to  nurse. 

*  Three  hundred  and  twenty-four  infants  were  put  on  artificial  feeding.  This 
feeding  consisted  of  feeding  at  the  laboratory  and  home  modifications.  One  himdred 
and  fifty-four  of  these  infants  were  supplied  with  wet-nurses,  owing  to  loss  of 
weight,  dyspeptic  conditions,  or  marasmus  during  the  bottle-feeding. 

'The  blood  of  every  wet-nurse  should  be  examined  for  a  Wassermann  reaction. 
The  danger  of  transmitting  syphilis  demands  this  precaution. 

7 


98  NUTRITION. 

ISTote  if  the  expressing  of  milk  causes  pain;  in  the  normal  breast  it 
should  be  painless. 

It  is  not  always  the  quality  of  the  milk,  but  frequently  the  quantity, 
that  is  the  cause  of  poor  assimilation  of  a  wet-nurse's  milk.  In  such  in- 
stances a  chemical  examination  of  the  milk  is  imperative;  by  this  we  can 
learn  exactly  how  much  we  feed  an  infant  in  percentages.  If  necessary, 
we  can  modify  the  milk  (by  proper  wet-nurse  diet)  until  the  required  per- 
centages are  attained. 

The  Child  of  a  Wet-nurse. — Certain  allowances  must  always  be  made 
for  babies  presented  by  wet-nurses — for  instance,  if  the  hygienic  surround- 
ings of  a  wet-nurse  are  very  poor,  and  in  addition  thereto  her  food  supply 
is  meager,  then  a  general  angemic  appearance  must  be  expected.  On  the 
other  hand,  'a  healthy,  robust-looking  baby  must  not  be  regarded  as  the 
criterion  by  which  we  should  judge  the  wet-nurse. 

The  tricks  of  wet-nurses  are  manifold.  Frequently  they  will  procure 
a  healthy-looking  infant  and  pass  it  off  as  their  own,  in  order  that  they  may 
procure  a  position. 

Another  point  is  that  they  will  frequently  resort  to  stuffing  their  babies 
by  feeding  a  bottle  in  addition  to  their  breast-milk.  Thus  we  must  judge 
for  ourselves  the  quality  of  the  wet-nurse  physically,  and,  most  important 
of  all,  by  the  quality  and  quantity  of  her  breast-milk. 

Health  of  the  Wet-nurse. — It  must  be  borne  in  mind  that  the  secretion 
of  milk  does  not  so  much  depend  on  her  constitution  as  it  does  depend  on 
her  nervous  system.  Great  importance  must  therefore  be  placed  on  the 
uselessness  of  hysterical  or  neurasthenic  women  for  wet-nursing. 

The  phlegmatic  temperament — the  broad-shouldered,  easy-going  woman 
— pleasant  and  gentle-mannered,  is  the  one  most  useful  and  best  adapted  for 
wet-nursing. 

Wet-rmrses  with  Goiter. — Bezy,  of  Toulouse,  considers  the  question: 
Should  women  affected  with  goiter  be  accepted  as  wet-nurses  ?  He  does  not 
think  so  because  there  is  a  certainty  of  danger  for  the  infant,  but  because  it 
is  more  prudent  to  exclude  such  women  from  nursing.  In  1897  he  saw  a 
fatal  case  of  tetany  in  an  infant  aged  six  months  in  wliich  no  cause  could 
be  found  for  the  disease  except  the  fact  that  the  mother  who  nursed  this 
baby  had  exophthalmic  goiter.  A  few  months  later  he  saw  another  case  of 
the  same  kind,  and  in  1898  he  saw  a  case  of  tetany  in  an  infant  aged  three 
months,  who  died  after  an  illness  of  about  forty  days  and  whose  nurse  had 
simple  goiter.  The  author  thinks  that  tetany  in  infants  may  be  of  thyroid 
origin,  and  that  the  thyroid  affections  of  the  nurse  are  transmitted  to  the 
nurslings.  •  He  does  not  pretend  to  establish  an  invariable  law,  but  simply 
wishes  to  call  attention  to  the  possibility  of  such  transmission  and  to  suggest 
further  investigations  on  the  subject. 

We  should  reject  a  wet-nurse  as  unfit  for  nursing  if  she  has : — 


WET-NURSE.  99 

1.  Enlarged  cervical  glands. 

2.  A  goiter. 

3.  Diseased  lungs,  no  matter  how  trivial. 

4.  Evidences  of  syphilis,  such  as  a  positive  Wassermann  reaction,  or 
condylomata. 

5.  Condylomata  on  her  genitals. 

6.  Mastitis. 

7.  Carious  teeth. 

Eecurring  menstruation  is  no  contraindication  for  a  wet-nurse.  Some 
women  are  perfectly  healthy  and  will  menstruate  regularly  during  their 
period  of  wet-nursing,  without  harm  to  the  infant. 

Erosions  or  fissures  on  the  nipple  should  not  be  looked  upon  as  contra- 
indications for  wet-nursing.  Infants  will  thrive,  although  changed  from 
one  wet-nurse  to  another.  Breast-milk  is  not  uniform  in  its  consistency. 
We  know  that  its  ingredients  not  only  change'  from  day  to  day,  but  that  the 
milk  varies  several  times  a  day.  In  spite  of  this  fact  children  thrive,  as 
was  demonstrated  by  Schlechter,  who  used  400  children  in  the  Vienna 
Foundling  Asylum.  Among  these  an  epidemic  of  gonorrhoeal  ophthalmia 
developed,  requiring  isolation.  Thus,  several  nurses  were  ordered  to  be 
isolated  with  these  infected  children,  and  it  was  noted  that  these  children 
developed  Just  as  well  in  spite  of  the  change  from  their  previous  breast-milk. 

The  mortality  in  this  same  institution  resulting  from  feeding  with 
sterilized  milk  has  been  entirely  done  away  with  since  the  introduction  of 
wet-nursing. 

Finally,  it  is  important  to  note  that  it  is  the  quality  of  milk,  rather 
than  the  quantity,  which  determines  the  value  of  breast-milk. 

When  children  are  strong  and  well-built,  and  have  a  ravenous  appetite, 
they  require  a  slow-flowing  hr east-milk,  as  a  rapid  flow  of  breast-milk,  aided 
by  a  hearty  appetite,  will  tend  to  overload  the  stomach,  and  is  one  of  the 
reasons  for  dyspepsia  in  young  children. 

It  is  a  good  point  to  try  to  secure  a  wet-nurse  suckling  a  child  about  as 
old  as  the  one  we  wish  her  to  nurse,  although  it  is  quite  common  to  find 
nurses  who  have  older  children  than  the  one  they  wish  to  nurse,  and  to  find 
the  latter  doing  well. 

The  proof  of  the  usefulness  of  the  wet-nurse  is  the  condition  of  the  baby 
after  some  time.  If  the  child  thrives  it  will  increase  in  weight.  Hence 
scales  must  be  frequently  used.  The  milk  should  be  examined  by  a  chemist 
to  determine  the  percentage  of  ingredients. 

Especial  note  should  be  made  of  the  percentage  of  fat  and  proteids. 

If  a  very  quick  examination  is  required,  then  a  microscopical  examina- 
tion of  one  drop  of  middle-milk  will  show  the  character  of  the  fat  globules. 

The  rough  method  of  examination  is  useful  when  the  life  of  the  infant 
is  at  stake  and  it  is  necessary  to  determine  quickly  whether  or  not  a  given 
wet-nurse  is  suitable  for  an  infant.     If  a  baby  suddenly  appears  colicky  or 


100 


NUTRITION. 


does  not  gain  in  weight  while  wet-nursing,  then  a  chemical  examination  of 
the  breast-milk  is  imperative.  We  can  frequently  find  an  excess  of  fat  or, 
more  often,  an  excess  of  proteids  as  the  cause  of  colic. 

Von  Bunge  presents  the  results  of  an  investigation  in  which  he  shows 
that  the  increasing  inability  of  mothers  to  nurse  their  infants  is  a  matter 
of  inheritance.  He  obtained  information  relative  to  665  cases  with  the 
following  result :  The  daughter  was  able  to  nurse  her  offspring  in  182  cases. 
The  mother  was  able  in  99.2  per  cent.,  and  unable  in  only  0.8  per  cent. 
The  mother  was  able  in  237  cases.  The  daughter  was  able  in  53.2  per  cent., 
and  unable  in  46.8  per  cent.  The  daughter  was  unable  to  nurse  her  off- 
spring in  483  cases.  The  mother  was  able  in  43.2  per  cent.,  and  unable  in 
56.8  per  cent.  The  mother  was  unable  in  147  cases.  The  daughter  was 
unable  in  99.3  per  cent.,  and  able  in  0.7  per  cent. 

He  concluded  from  the  foregoing  figures  that  inability  to  nurse  is 
largely  a  matter  of  inheritance.  Further  inquiries  also  led  him  to  believe 
that  tuberculosis  and  nervous  diseases  were  to  a  considerable  extent  asso- 
ciated with  inability  to  nurse  one's  offspring.  But  much  more  prominent 
appears  to  be  the  relation  of  intemperance.  Where  the  mother  and  daughter 
were  both  able  to  nurse  he  found  that  the  fathers  were  usually  at  least  mod- 
erate in  the  use  of  alcohol,  and  only  in  4.5  per  cent,  were  they  hard  drinkers. 
On  the  other  hand,  when  the  mother  was  able  to  nurse,  but  the  daughter 
was  unable,  it  was  found  that  the  father  was  often  intemperate,  and  in  46.8 
per  cent,  was  an  actual  drunkard.  In  this  inquiry  the  author  considered 
those  only  as  able  to  nurse  who  could  nurse  all  their  children  for  a  period 
of  nine  months.    All  others  as  unable. 

The  control  of  wet-nurses  was  very  adequately  discussed^  as  a  public 
prophylaxis.  Many  believed  it  was  a  matter  that  could  be  brought  under 
the  control  of  the  law. 

Dr.  Petrini,  of  Galatz,  professor  at  the  University  of  Bucharest,  pre- 
pared an  elaborate  report  in  which  the  prevalence  of  infection  of  sylDhilis  by 
means  of  wet-nurses  was  demonstrated.  He  showed  that  its  frequency  varied 
widely  in  different  countries,  and  hence  an  English  view,  for  instance,  of  its 
comparative  importance,  drawn  from  the  rarity  of  the  infection  in  that 
country,  was  not  a  criterion  for  the  whole,  since  it  had  been  shown  for 
Oriental  lands,  and  even  for  Paris,  that  it  was  an  important  element. 

He  proposes  a  special  medical  service,  working  in  co-operation  with 
municipal  authorities  and  having  for  its  head  a  competent  syphilographer. 
All  children  being  nursed  by  wet-nurses  should  be  inspected  regularly  by 
representatives  of  this  bureau,  and  all  wet-nurses  should  receive  authoriza- 
tion for  their  calling  by  the  same  bureau  after  rigorous  medical  examina- 
tion.   Special  provision  should  be  made  for  syphilitic  children. 


*  Second  International  Conference  for  the  Prevention  of  Syphilis  and  Venereal 
Diseases,  held  at  Brussels,  Belgium,  Septemher  I  to  6,  1902. 


WET-NURSES'  MILK.  JQI 


Clinical  Iblustrations  of  the  Variations  in  Wet-nurses'  Milk. 

The  following  case  will  illustrate  the  peculiarity  of  breast-milk  in  a 

wet-nurse : — 

Case  I. — First  examination  of  breast-milk  showed: — 

Fat    2.50 

Milk-sugar    6.50 

Protein  1.93 

Mineral  matter   0.21 

Total  solids    11.14 

Water    88.86 

When  the  wet-nurse  was  first  employed,  the  infant  gained  more  than  eight 
ounces  each  week.  Had  yellowish  stools,  one  or  two  each  day.  Slept  well  after 
nursing  and  appeared  satisfied.     Cried  only  at  feeding  time.     No  evidence  of  colic. 

A  second  examination  of  the  breast-milk  was  made  to  compare  the  character  of 
the  milk  with  that  of  the  first  specimen: — 

Fat 2.10 

Milk-sugar    6.50 

Protein    1.41 

Mineral  matter  0.15 

Total  solids    10.16 

Water 89.84 

Two  months  later,  same  wet-nurse.  Child's  weight  stationary.  Green,  curded 
stools;  cries  and  has  colicky  pains.  Restless  at  night.  Wet-nurse  is  menstruating. 
Chemical  analysis  of  milk  shows: — 

Fat    0.65 

Milk-sugar 6.50 

Protein    1.12 

Mineral  matter   0.11 

Total  solids    8.38 

Water    91.62 

With  the  aid  of  cereals  and  malt,  also  a  change  from  the  city  to  the  seashore, 
the  milk  improved.  The  infant  was  more  satisfied.  The  stools  again  assumed  a 
yellowish  color.     One  month  after  this  building-up  treatment,  an  analysis  of  the 

breast-milk  showed: — 

Fat 3.50 

Milk-sugar    6.50 

Protein   1.90 

Mineral  matter    0.19 

Total  solids  12.09 

Water  87.91 


102  NUTRITION. 

When  the  infant  was  eight  months  old  the  secretion  of  milk  was  scanty,  so 
that  the  breast  was  alternated  with  bottle-feeding.  The  general  condition  improved. 
The  child  was  again  satisfied.    A  chemical  examination  of  the  breast-milk  showed: — 

Fat 3.00 

Milk-sugar    6.50 

Protein    1.08 

Mineral  matter 19 

Total  solids   10.77 

Water    89.23 

As  the  proteins  were  found  to  be  very  low,  I  ordered  the  white  of  a  raw  egg, 
soup,  and  expressed  beef  juice.  When  the  child  was  nine  months  old  it  was  neces- 
sary to  wean  it,  as  the  wet-nurse  had  very  little  milk. 

In  this  ease  the  stationary  weight,  the  colicky  condition,  and  the  char- 
acter of  the  stools  were  important  guides,  and  fully  agreed  with  the  analyses 
of  the  specimens  given. 

Case  II. — Colic. — ^An  infant  five  months  old  suffered  with  severe  colic.  It  cried 
continuously,  especially  after  nursing.  Relief  was  afforded  when  castor-oil  was  given 
or  when  warm  colon  fiushing  was  resorted  to.  Diluting  the  breast-milk  by  giving 
an  ounce  or  two  of  barley  or  rice  water  immediately  after  each  nursing  seemed  to 
modify,  but  not  altogether  relieve,  this  condition.  The  chemical  examination  of 
the  milk  gave: — 

Fat 6.59 

Sugar     6.69 

Protein 1.16 

Ash , 19 

Total  solids    14.63 

Water 85.37 

The  excessive  amount  of  the  fat  was  evidently  the  cause  of  the  trouble.  The 
quantity  of  meat  was  reduced.  Exercise  was  ordered  and  beer  forbidden.  In  a  few 
weeks  the  percentage  of  fat  in  the  milk  was  greatly  reduced,  and  the  infant  far 
more  comfortable. 

"  o' 
Ooo 

%  O  „    oo       o         °. 

O^  O   a, 

Case  III. — Fig.  35. — Specimen  of  Breast-milk  Taken  from  a  Wet-nurse  during 
Menstruation,  Illustrating  the  Poor  Character  of  the  Emulsion.     (Original.) 


DIET  OF  A  WET-NURSE.  103 

The  infant  was  very  restless,  and  had  colicky  attacks.  Note  the  small,  un- 
evenly divided  fat  globules — irregular  form  of  the  larger  globules.  It  appears  to 
be  a  very  watery  emulsion.  Chemical  examination  of  the  specimen  showed:  Fat, 
1.60;   sugar,  6.50;    protein,  2.43.     The  baby  did  not  gain  during  the  whole  week. 

Case  IV. — Good  Milk  in  a  'Wet-nurse. — In  this  case  we  have  a  child  that  was 
gaining  in  weight.  Appeared  satisfied  after  nursing,  but  had  a  tendency  toward  con- 
stipation.    A  chemical  analysis  of  the  milk  gave: — •  * 

Fat    4.20 

Sugar  *. 6.50 

Protein    2.80 

Ash    28 

Total   solids    13.78 

Water    86.22 

Diet  of  a  Wet-nuese. 

The  diet  given  for  a  nursing  mother  can  also  be  used  as  a  guide  in 
choosing  the  diet  for  a  wet-nurse.  The  greatest  care,  however,  must  be 
bestowed  on  the  manner  of  living. 

Manner  of  Living. — A  wet-nurse  that  was  a  former  servant,  or  worked 
out  of  doors,  and  is  suddenly  taken  into  this  new  mode  of  life  and  given 
charge  of  a  baby,  must  have  proper  exercise.  Otherwise  she  will  very  soon 
secrete  milk  which  will  be  totally  unfit  for  an  infant,  and  as  a  result  the 
child  will  probably  have  severe  colic  and  irregular,  cheesy  stools ;  will  vomit 
excessively,  and  will  not  gain  sufficiently  in  weight.  It  is  therefore  impor- 
tant to  try  to  adapt  a  wet-nurse  to  the  same  condition  as  existed  prior  to 
her  pregnancy;  so  that  both  her  manner  of  living  and,  chiefly,  her  diet 
shall  not  be  different. 

That  alcohol  may  be  eliminated  from  milk  is  shown  by  a  case  reported  by  Val- 
lani.  A  nursing  infant  was  seized  with  convulsions  with  great  regularity  on  Mon- 
day and  Thursday,  but  was  quite  well  on  other  days.  Investigation  showed  that 
the  wet-nurse  on  Sundays  and  W^nesdays  (her  days  out)  was  in  the  habit  of  drink- 
ing freely  of  alcohol.  The  curtailment  of  these  privileges  resulted  in  the  disappear- 
ance of  the  convulsions. 

Proper  Rest. — To  be  equal  to  her  task  a  nurse  must  be  given  plenty 
of  sleep,  if  it  is  at  all  possible. 

Adriance,  in  the  Archives  of  Pediatrics,  says: 

1.  Excessive  fats  or  proteins  may  cause  gastro-intestinal  symptoms  in 
the  nursing  infant. 

2.  Excessive  fats  may  be  reduced  by  diminishing  the  nitrogenous  ele- 
ments in  the  mother's  diet. 

3.  Excessive  protein  may  be  reduced  by  the  proper  amount  of  exercise. 

4.  An  excess  of  protein  is  especially  apt  to  cause  gastro-intestinal  symp- 
toms during  the  colostrum  period. 


104  NUTRITION. 

5.  The  protein,  being  higher  during  the  colostrum  period  of  prema- 
ture confinement,  presents  dangers  to  the  untimely  bom  infant. 

6.  Deterioration  in  human  milk  is  marked  by  a  reduction  in  the  pro- 
tein and  total  solids,  or  in  the  protein  alone. 

7.  This  deterioration  takes  place  normally  during  -the  later  months  of 
lactation,  and  unless  proper  additions  are  made  to  the  infant's  diet,  is 
accompanied  by  a  loss  of  weight  or  a  gain  below  the  normal  standard. 

8.  When  this  deterioration  occurs  earlier,  it  may  be  the  forerunner  of 
the  cessation  of  lactation,  or  well-directed  treatment  may  improve  the  condi- 
tion of  the  milk. 

Methods  of  Chaistgikg  the  Ingredients  in  Woman's  Milk. 

Eotch  gives  a  condensed  table  for  these  changes  as  follows : — 

To  Increase  the  Total  Quantity. — Increase  the  liquids  in  the  mother's 
diet,  especially  milk  (malt-extracts  may  be  helpful),  and  encourage  her  to 
believe  that  she  will  be  able  to  nurse  her  infant. 

To  Decrease  the  Total  Quantity. — Decrease  the  liquids  in  the  mother's 
diet. 

To  Increase  the  Total  Solids. — Shorten  the  nursing  intervals,  decrease 
the  exercise,  decrease  the  proportion  of  liquids,  and  increase  the  proportion 
of  solids  in  the  mother's  diet. 

To  Decrease  the  Total  Solids. — Prolong  the  nursing  intervals,  increase 
the  exercise,  and  increase  the  proportion  of  liquids  in  the  mother's  diet. 

To  Increase  the  Fat. — Increase  the  proportion  of  meat  in  the  diet. 

To  Decrease  the  Fat. — Decrease  the  proportion  of  meat  in  the  diet. 

To  Increase  the  Protein. — Increase  the  exercise  up  to  the  limit  of 
fatigue  for  the  individual. 

It  is  wise  in  all  cases  of  disturbed  lactation^  whether  in  maternal  or 
wet-nursing,  to  make  efforts  in  accordance  with  these  rules  to  produce  a  milk 
that  is  suitable  for  an  infant  who  is  not  thriving,  before  changing  to  any 
other  method  of  feeding. 

Wet-nursing. 

It  is  an  established  fact  that  the  best  possible  food  for  an  infant  is 
breast-milk.  Where  the  mother  of  an  infant  is  prevented  from  nursing 
her  child,  the  next  thing  to  be  considered  is  wet-nursing.  That  nursing  a 
child  is  an  advantage  to  the  mother  is  a  well-known  fact,  inasmuch  as  it 
influences  the  contraction  of  the  uterus  and  stimulates  the  circulation. 
Contrary  to  the  belief  that  nursing  a,  child  is  detrimental  and  contraindi- 
cated  in  women  whose  lungs  are  weak  and  who  have  a  tendency  to  tuber- 
culosis, it  does  them  no  harm,  and,  indeed,  seems  to  do  them  good.  This 
statement  is  borne  out  by  the  experience  of  Dr.  Heinrich  Munk,  of  KarFs- 
bad,  Austria,  a  specialist  in  the  diseases  of  women. 


WET-NURSING.  105 

In  Austria  the  state  supports  public  institutions  for  lying-in  women. 
Tliey  are  kept  there  and  confined  gratis,  and  remain  about  fourteen  days. 
They  are  admitted  into  these  hospitals  in  the  last  months  of  pregnancy. 
Vienna  usually  has  about  300  women  on  hand.  Prague  constantly  has  100 
women  in  this  condition,  who  are  utilized  for  the  purpose  of  instruction  to 
physicians  and  midwives. 

In  Prague  there  are  about  3000  women  confined  annually,  and  these 
women  are  put  into  the  foundling  asylum.  There  they  remain  until  they 
procure  a  place  as  a  wet-nurse  or  as  long  as  their  services  are  needed  in  the 
asylum.  When  wet-nurses  are  taken  from  the  foundling  asylum,  it  is  a 
frequent  occurrence  to  have  those  remaining  therein  nurse  at  least  two  chil- 
dren, and  frequently  three,  at  one  time.  In  this  manner  they  dispense  grad- 
ually with  these  wet-nurses  without  hurting  the  remaining  children.  Many- 
children  die,  some  of  them  intrapartum  in  operative  confinements,  and  the 
women  (mothers  of  such  children)  are  then  utilized  for  wet-nursing.  It 
is  a  rule  to  keep  the  children  in  the  asylum  until  they  have  attained  a  little 
over  4  kilograms  (about  9  pounds),  and  they  are  then  put  out  for  further 
feeding  (artificial  feeding),  for  which  the  city  pays  about  13  florins  ($5.00) 
a  month.  The  children  remain  usually  until  they  are  6  years  old,  and  are 
then  given  back  to  their  own  mothers.  Many  of  these  children  die;  others 
are  adopted  by  those  who  have  reared  them,  but  the  greater  portion  are 
taken  back  to  their  own  mothers.  In  Vienna  there  are  about  10,000  con- 
finements annually  in  the  public  institution.  There  are  a  great  many  cities 
in  Austria — like  Innsbruck-Olmutz,  Brunn,  Linz,  and  Klagenfurt — where 
there  are  at  least  200  confinements  annually.  In  Vienna  a  wet-nurse  receives 
30  florins  per  month,  for  which  she  is  sent  (railroad  expenses  paid)  to 
whoever  requires  her  services.  She  is  taken  on  trial  for  fourteen  days  to  see 
if  she  is  adapted  for  her  place.  A  wet-nurse  can  be  procured  by  sending  a 
telegram  and  a  money  order  any  day  during  the  year.  The  customary  wages 
are  from  12  florins  upward  per  month.  Each  wet-nurse  is  carefully  exam- 
ined by  the  professor  before  she  is  sent  away.  A  great  many  families  do 
not  care  to  take  a  wet-nurse  from  an  asylum,  as  they  are  usually  women  of 
the  lowest  walks  of  life,  and  they  prefer,  therefore,  to  take  a  woman  who 
has  been  married.  For  this  purpose  agencies,  duly  licensed,  exist.  These 
will  supply  wet-nurses,  and  usually  take  orders  in  advance ;  thus  a  wet- 
nurse  may  be  reserved.  Such  wet-nurses  cost  much  more,  and  those  from 
one  special  region — Iglau,  in  Mahren — receive  from  20  to  50  florins  monthly. 

The  Empress  took  a  wet-nurse  from  Iglau  (a  married  woman),  and 
the  Princess  of  Bulgaria  took  a  wet-nurse  from  Iglau  for  her  last  child. 
Not  only  Iglau,  but  the  whole  region,  is  renowned  for  its  excellent  quality 
of  wet-nurses.  The  Bohemian  and  Mahren  nurses  have  very  good  mammae. 
They  seem  to  love  the  children  entrusted  to  them.  In  America  the  wet- 
nurses  are  uneducated  servants. 


106 


NUTRITION. 


While  it  is  a  rule  that  a  wet-nurse  should  be  taken  for  an  infant  of  the 
same  age  as  that  of  her  own,  frequently  wet-nursing  of  an  infant  at  birth 
by  a  wet-nurse  whose  baby  is  three  months  old  has  not  been  followed  by  any 
bad  results. 

In  New  York  we  are  at  a  decided  disadvantage  regarding  wet-nurses. 
As  no  licensed  agents  exist,  a  few  people  procure  wet-nurses  from  superin- 
tendents and  house  physicians  of  hospitals  where  obstetrical  work  is  done. 

The  importance  of  properly  supervising  wet-nurses  in  the  light  of  the 
danger  of  transmitting  syphilis  needs  no  further  comment.  The  Health 
Department  in  every  city  should  grant  the  use  of  their  laboratories  for  a 


Fig.  36. — Pear-shaped  Breasts,   Best  Adapted  for  Nursing.      (Original.) 

careful  blood  examination  of  each  and  every  wet-nurse.  It  is  as  important 
to  prevent  the  transmission  of  syphilis  to  a  child  as  it  is  to  give  an  im- 
munizing dose  of  antitoxin  to  prevent  diphtheria. 

Being  positive  that  the  blood  of  the  wet-nurse  is  not  diseased,  our 
next  examination  should  be  of  the  milk.  A  wet-nurse  whose  milk  contains 
colostrum  corpuscles  should  be  rejected  until  the  colostrum  corpuscles  have 
disappeared.  The  chemical  examination  of  the  milk  should  be  made  to 
ascertain  the  percentage  of  fat.  Milk  that  contains  more  than  2  per  cent, 
of  fat  should  not  be  used.  If  the  wet-nurse  selected  has  an  exceptionally 
large  quantity  of  milk  and  is  otherwise  healthy,  then  the  milk,  if  it  contains 
too  much  fat,  may  be  pumped  off  with  a  breast-pump  and  diluted  with 
water,  and  so  fed  from  a  nursing  bottle. 

It  is  a  pity  that  we  have  no  municipal  control  for  what  the  writer 
considers  one  of  the  most  valuable  adjuncts  to  our  infant-feeding,  and  in 


WEANING  AND  FEEDING  FROM  ONE  YEAR  TO  FIFTEEN  MONTHS.       107 

the  same  manner  such  control  would  regulate  the  supply  to  such  unlimited 
number  that  modern  arrogance  on  the  part  of  the  wet-nurse  would  probably 
disappear. 

The  prices  paid  in  New  York  are  from  $4.0  to  $50  per  month  and  board, 
and  this  price  prohibits  many  an  infant  from  securing  the  benefits  of 
Nature's  food.    Let  us  hope  for  municipal  regulation. 

Weaning  and  Feeding  from  One  Year  to  Fifteen  Months. 

When  the  teeth  appear,  weaning  must  be  considered.  If  the  nursing 
mother  becomes  pregnant  weaning  is  imperative. 

The  condition  of  the  infant,  its  sleep,  its  stool  and  its  weight  are  fac- 
tors that  should  influence  the  decision  to"  wean.  In  some  infants  gradual 
weaning  may  be  attempted,  but  in  most  infants  successful  weaning  can  best 
be  accomplished  by  the  absolute  cessation  of  the  breast. 

If  the  infant  has  not  gained  in  weight,  puts  its  fingers  into  its  mouth, 
cries  or  whines  after  the  breast  feeding,  and  if  the  stools  are  thin  and  watery, 
then  weaning  is  imperative.  Such  an  infant  will  gain  in  weight  and  be 
better  satisfied  when  given  the  following  formula : — 

Whole  milk   6  ounces 

Sterile  water  2  ounces 

Malt  sugar   1  teaspoonful 

Heat  until  the  steam  rises.    Feed  the  above  quantity  every  four  hours. 

An.  infant  nine  months  old  may  have  a  saucer  of  well-steamed  (two 
hours)  farina,  hominy  or  Pettijohn,  one-half  hour  before  the  second  feeding 
each  morning.  The  juice  of  one-half  pound  of  broiled  steak  can  be  secured 
with  a  meat  press  and  fed  every  other  day  at  noon.  A  saucer  of  rice 
steamed  in  equal  parts  of  milk  and  water,  or  half  a  cup  of  junket,  may  be 
fed  before  the  6  p.m.  bottle.  When  constipation  exists  the  juice  of  an 
orange  or  the  pulp  of  stewed  prunes  pressed  through  a  strainer  may  be  given 
one  hour  before  a  milk  feeding.  Crackers,  zwieback,  and  biscuits  may  be 
given,  but  all  floury  foods  tend  to  constipate.  In  the  bottle  8  ounces  of 
whole  milk  steamed  about  five  minutes  may  be  given.  The  addition  of  one 
teaspoonful  of  Loefflund's  malt  soup  to  each  bottle  will  offset  constipation. 
If  a  tendency  to  loose  bowels  exists,  the  cream  should  be  skimmed  from  the 
milk,  and  this  fat-free  milk  boiled.  The  addition  of  limewater  is  indicated 
where  looseness  exists. 

6.00  A.  M Breast 

9.30  A.  M Cereal 

10.00  A.  M Bottle 

2.00  P.  M Breast 

5.30  P.  M Cereal  or  junket 

6.00  P.  M Bottle 

10.00  P.  M.    . .  . ; Breast 


108 


NUTRITION. 


Weight  and  Development. 

When  a  child  develops  normally,  it  gains  in  weight.  Breast-fed 
infants,  as  a  rule,  gain  more  than  bottle-fed  infants.  The  progress  of  an 
infant  can  be  watched  by  a  comparison  with  its  weight.  The  moment  a 
child's  weight  is  stationary,  the  reason  for  the  same  should  be  ascertained. 


Fig.  37. — The  Chatillon  Scale  is  a  very  convenient  basket  scale.     It  is  very- 
useful  in  the  nursery. 


If  the  baby  is  breast-fed  the  milk  of  the  nursing  mother  should  be  sent  to 
a  chemist  for  examination.  (The  details  have  already  been  described  in 
the  article  on  "Breast-milk.") 

Disturbances  of  the  mother  interfering  with  proper  lactation  are  at 
once  evident  in  her  milk.  Such  disturbances  are:  (a)  menstruation;  (&) 
general  anaemia;  (c)  tuberculosis,  and  (d)  pregnancy  will  frequently  alter 
the  percentage  of  the  ingredients  of  milk  so  that  a  child  will  not  receive 
sufficient  nutrition. 

The  first  evidence  of  such  malnutrition  will  be  seen  on  the  scales. 
The  child  will  not  gain  in  weight,  and  frequently  it  will  lose  weight. 


WEIGHT  IN  BREAST-FEEDING.  109 

How  Much  Should  an  Infant  Weigh? — The  average  weight  at  birth 
is  7  pounds.  Some  children  weigh  considerably  more  and  some  less.  A 
child  should  double  its  weigbt  at  the  end  of  five  months,  and  treble  its 
weight  at  the  end  of  the  first  year.  It  must  not  be  supposed  that  because 
a  child  weighs  less  than  this  amount  it  may  not  be  healthy.  All  fac- 
tors should  be  taken  into  consideration  and  a  child  should  be  carefully 
examined  to  determine  whether  or  no  it  is  normal.  Very  many  babies  are 
up  to  the  normal  in  weight,  and  still  show  marked  rachitis.  The  very  fat 
and  flabby  baby — usually  supposed  to  be  extremely  healthy  by  the  laity — 
is  the  one  in  whom  physicians  most  frequently  meet  with  constitutional 
disorders.  Thus,  too  much  stress  should  not  be  put  on  the  scales,  for  we 
know  that  they  have  their  limitations.  In  the  beginning,  or  during  the  first 
and  second  months,  a  normal  infant  gains  about  6  to  8  ounces  a  week.  Dur- 
ing the  third  month  a  child  gains  from  4  to  6  ounces  per  week,  and  after  the 
third  month  from  3  to  4  ounces  per  week. 

Weighing  Immediately  After  Nursing  to  Determine  the  Quantity  of 
Milk  an  Infant  has  Taken. — When  scanty  milk  supply  is  suspected  in  either 
the  nursing  mother  or  in  a  wet-nurse,  then  we  can,  in  some  instances,  resort 
to  weighing  immediately  after  the  baby  has  nursed.  It  is  understood  that 
the  child  must  be  weighed  both  immediately  before  nursing  and  then  imme- 
diately after  nursing.  The  difl^erence  in  weight  is  the  amount  of  milk 
^.wallowed. 

While  this  may  serve  in  some  cases,  the  author  has  not  found  it  very 
practical,  and  cannot  recommend  it,  excepting  in  rare  instances. 

It  is  well  known  that  an  infant  whose  stomach  is  filled  requires  rest 
after  nursing,  and  the  less  it  is  handled  the  less  is  the  chance  for  expelling 
its  food.  Thus,  my  advice  is  not  to  handle  or  fumble  with  a  child  after 
nursing,  but  rather  aid  Nature  in  resting  an  infant  than  provoke  vomiting 
by  unnecessary  handling. 


Table  No.  17. 
Tahle  Showing  the  Gain  of  a  Healthy  Infant  Fed  at  the  Breast. 

Normal    weight  at    birth,    7              Gain  at  the  end  of  the  first 

ib.  week,  none. 

Weight  when  2  weeks  old,  7              Gain  at  the  end  of  2  weeks,  6 

lb.  6  oz.  oz. 

Weight  when  3  weeks  old,  7              Gain  at  the  end  of  3  weeks,  8 

lb.  14  oz.  oz. 

Weight  when  4  weeks  old,  8              Gain  at  the  end  of  4  weeks,  8 

lb.  6  oz.  oz. 


110 


NUTRITION. 


The  following  cases  will  serve  to  illustrate  the  weight  of  infants  with 
various  methods  of  feeding — {a)  breast-feeding,  (&)  home  modification, 
(c)  laboratory  feeding : — 


fi&£-   IN  V/EEKS 


Fig.  38.      (Original.) 


Baby  Robert  M.  F,  Normal  at  birth.  Was  wet-nursed.  Gain,  first  month, 
2%  pounds;  second  month,  li%6  pounds;  third  month,  1%  pounds;  fourth  month, 
1^^  pounds.  Stools  were  normal.  Had  gastric  disturbances  and  symptoms  of 
colic  while  the  wet-nurse  menstruated.  When  the  child  was  about  seven  months 
old  the  chemical  analysis  of  the  breast-milk  showed  a  deficiency  of  fat  and  quite  a 
high  percentage  of  proteins.  The  milk  supply  gradually  gave  out  and  it  was 
necessary  to  wean  the  child. 


WEIGHT  IN  ARTIFICIAL  FEEDING. 


Ill 


^c^tm\»<2.eXv^ 


i3iff-  f-f/i  n  /SJ9ZO 


TFTrfrTTTTrFrNv 


::^^ 


Fig.  39.      (Original.) 

Baby  J.  S.  Born  prematurely.  Weighed  5  pounds  14  ounces  at  birth.  Was 
bottle-fed.  Vomited;  had  dyspeptic  symptoms,  such  as  cheesy  stools,  restlessness 
at  night,  crying  continually,  and  excoriated  anus.  When  one  month  old  the  weight, 
including  shirt  and  diaper,  was  6  pounds.  A  wet-nurse  was  procured.  The  child 
gained  1  pound  during  the  iirst  week,  and  an  average  of  10  ounces  a  week  thereafter. 
Dyspeptic  symptoms  disappeared;  stools  became  normal.  The  child  was  not  seen  for 
six  months,  and  is  a  perfectly  healthy  baby  today. 


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Fig.  40.     (Original.) 

From  baby  fed  on  Eskay's  food  since  end  of  third  week.     General  condition 
satisfactory,  although  somewhat  constipated. 


112 


NUTRITION. 


QcO>'lVXN.mt&\5.S 


Fig.  41.     (Original.) 

Baby  A.  Case  of  chronic  dyspepsia.  Child  four  months  old.  Weighed  8  pounds 
15  ounces.  Gained  13  ounces  the  first  week  of  treatment;  6  ounces  the  second  week; 
7,  12,  9  ounces  respectively  during  each  of  the  succeeding  weeks. 


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Fig.  42.     (Original.) 

Baby  D.  S.     Weighed  5  pounds  at  birth.     Was  fed  at  Walker-Gordon  Labora- 
tory since  six  weeks  old.    Lost  weight  during  an  attack  of  measles  when  twenty-six 


WEIGHT  IN  PERCENTAGE  FEEDING.  113 

weeks  old.     Did  not  gain  one  ounce  from  the  thirty-eighth  to  the  forty-second  week, 
although  received  a  formula  of: — 

Fat    4.00 

Sugar    6.50 

Protein    2.50 

Six  feedings,  of  seven  ounces  each. 

I  ordered  tlie  following  home  modification : — ■ 

Raw  milk 6  ounces 

Barley  water   2  ounces 

Mellin's  food   2  teaspoonfuls 

Feed  every  three  hours. 

In  addition  thereto  I  ordered  one  ounce  of  steak  juice  or  one  ounce  of 
orange  juice,  daily,  one  hour  before  feeding. 

I  also  gave  the  white  of  one  raw  egg  with  the  evening  feeding.  The 
food  agreed  very  well  and  child  gained  in  weight  as  I  gradually  added  more 
milk  and  reduced  the  quantity  of  barley  water. 

A  growing  child  needs  far  more  food  than  its  weight  alone  would 
indicate,  for  its  income  must  exceed  its  expenditure  so  that  it  may  grow. 
An  infant  for  the  first  seven  months  or  first  one-half  year  of  life  should 
have  nothing  but  milk.  Up  to  this  age  vegetable  food  is  unsuited  to  it; 
it  is  purely  a  carnivorous  animal. 

The  diet  of  the  infant  is  nearly  twice  as  rich  in  proteins,  half  as  rich 
again  in  fats,  and  a  little  more  than  half  as  rich  in  carbohydrates  as  that 
of  the  adult.    It  is,  therefore,  in  a  physiologic  sense  a  luxurious  diet. 

The  strain  of  growth  falls  heavier  upon  the  more  precious  proteins  than 
upon  the  more  cheap  and  common  carbohydrates.^ 

When  children  do  not  gain  in  weight,  the  quantity  of  sugar  should 
be  increased.  This  should  be  done  continuously  and  with  due  consideration 
for  the  other  ingredients. 

The  constructive  ingredient  in  an  infant's  food  is  the  proteins.  We 
must,  therefore,  consider  this  element  when  an  infant's  weight  is  stationary. 

Individual  conditions  must  be  considered,  and  chronic  disorders  elim- 
inated, e.g.,  dyspeptic  conditions  or  tuberculosis,  before  arriving  at  a  diag- 
nosis of  what  really  causes  an  infant's  loss  in  weight. 


"Stewart's  Physiology,"  p.  412,  1S97. 


CHAPTBE  II. 

COWS'  MILK. 

Hammersten^  gives  the  following  analysis  of  cows'  milk  in  a  thou- 
sand parts  as  follows: — 

Water 874.2 

Solids    125.8 

Fat    36.5 

Sugar 48.1 

Salt 7.1 

Protein   (casein,  28.8;   albumin,  5.3)    34.1 

A.  Baginsky^  gives  the  following  analysis  of  cows'  milk,  made  at  the 
Kaiser  and  Kaiserin  Friedrich  Hospital,  Berlin: — 

Water 87.60 

Solids   - 12.38 

In  one  hundred  parts. 

The  solids  consist  of : — 

Casein  and  albumin   3.65 

Butter    3.11 

Milk-sugar    , 4.54 

Inorganic  salts    1-08 

Besides  large  amounts  of  potassium  and  potassiimi  salts  and  small 
quantities  of  iron. 

Composition,  Variation,  and  Production. — Milk  of  all  animals,  roughly 
speaking,  is  composed  of  the  same  ingredients,  but  an  analysis  of  milk  is 
apt  to  be  very  misleading,  as  it  does  not  show  the  physical  condition  of  the 
milk,  which  is  the  important  thing  to  know,  from  the  physician's  standpoint. 

The  general  ingredients  of  milk  are  fat,  sugar,  albumin,  casein,  salts, 
and  water.  These  ingredients  vary  in  quantity  from  day  to  day,  and  from 
milking  to  milking.  An  average  analysis  of  a  woman's  milk  does  not  show 
what  an  infant  is  getting,  by  any  means,  for  the  composition  of  the  milk 
depends  upon  the  food,  the  health  of  the  mother,  and  the  frequency  of 
nursing. 

The  Breed  of  a  Cow, — Some  l)reeds  yield  quantity;  others  quality. 
Holsteins  produce  the  most  milk;  Alderneys  and  Jerseys  yield  the  most 
fat;  Shorthorns  give  the  most  casein  and  sugar.  The  average  capacity  of 
a  cow's  udder  is  about  5  pints,  and  the  annual  yield  of  milk  is  about  600 
gallons. 

^  "Physiological  Chemistry." 
""Diseases  of  Children,"  1899,  page  32. 

(114) 


COWS'  MILK.  115 

Time  and  Stage  of  Milking. — Cows  are  usually  milked  twice  a  day, 
the  morning  milk  usually  being  larger  in  quantity  and  poorer  in  quality. 
The  milk  which  is  first  drawn  is  known  as  the  fore-milk,  and  contains  very 
much  less  fat  than  that  last  drawn,  known  as  the  strippings.  This  is  due 
to  a  partial  creaming  taking  place  in  the  udders.  Dishonest  dealers  have 
often  taken  advantage  of  this  fact  in  adulteration  cases  to  have  the  cows 
partially  milked  in  the  presence  of  ignorant  witnesses,  the  resulting  milk 
consisting  largely  of  the  fore-milk. 

Age  of  Cows. — Young  cows  give  less  milk,  while  cows  from  four  to 
seven  years  old  give  the  richest  milk,  and  less  milk  is  given  with  the  first 
calf.  They  give  the  largest  yield,  according  to  Fleishmann,  after  the  fifth 
until  the  seventh  calf;  after  the  fourteenth  calf  they  yield,  as  a  rule,  no 
more  milk.  The  poorest  milk  is  yielded  during  the  spring  and  early  sum- 
mer; the  richest  during  the  autumn  and  early  winter.  If  cows  are  worried 
or  driven  about,  the  quality  and  quantity  of  the  milk  are  reduced.  If  they 
"are  kept  warm  and  well  fed,  both  quantity  and  quality  are  naturally  in- 
creased. 

According  to  Rotch,  the  Durham,  or  Shorthorn,  represents  the  best  type 
of  cow  for  this  purpose.  She  has  great  constitutional  vigor,  great  capacity 
for  food,  a  perfect  digestion,  and,  most  important  of  all,  a  quiet  tempera- 
ment.   The  analysis  of  her  milk  is  as  follows : — 

Per  cent. 

Fat    4.04 

Sugar    4.34 

Proteins 4.17 

Mineral  matter    0.73 

Total  solids 13.28 

Water    86.72 


100.00 


The  Devon  is  another  breed  of  cow  having  the  same  characteristics  as 
the  Durham.  They  are  gentle  and  vigorous,  and  yield  a  large  quantity  of 
rich  milk,  the  analysis  of  which  is  as  follows  :— 

Per  cent. 

Fat    4.09 

Sugar 4.32 

Proteins     4.04 

Mineral  matter   0.76 

Total   solids    13.21 

Water    86.79 

100.00 


116  NUTRITION. 

The  Ayrshire,  another  type,  while  representing  strength,  is  somewhat 
nervous,  and  while  not  as  hardy  as  the  Durham,  they  are  '.free  from  disease 
and  yield  a  large  quantity  of  n>ilk,  the  analysis  of  which'  is  as  follows:— 
'     ' .    ■  '  Per  cent. 

Fat   ;... ....;.C;. ■.;.;.  ...-..:. :..:..     3.89 

Sugar    : ;....... ■.:■ ..4.41 

Proteins , 4.01 

Mineral   matter    0.73 

Total   solids    r: ......:..:...  .    13.04 

Water    •'..'': ;    86.96 


100.00 


The  Holstein-Friesian,  commonly  called  Hohtein,  represents  the  most 
perfect  type  of  cow.  She  yields  a  large  quantity  of  milk,  though  light  in 
its  total  solids.    The  following  is  the  analysis:^ 

Per  eentr  ' 

Fat 2.88    ,  r 

Sugar    4.33 

Proteins 3.99 

Mineral  matter '. 0.74 

Total   solids ...;....: ;......:....  i,..  11.94  ,       u 

Water 88.06 


100.00 


Some  of  the  marks  which  distinguish  the  breeds  of  cows  best  adapted 
for  infant  feeding  are : — 

1.  Constitutional  vigor. 

2.  Adaptability  to  acclimatization. 

3.  Notable  ability  to  raise  their  young. 

4.  Freedom  from  intense  inbreeding. 

5.  A  distinctly  emulsified  fat  in  the  milk. 

6.  A  preponderance  in  the  fats  of  the  fixed  glycerides  over  the  vola- 
tile glycerides.  . 

The  volatile  glycerides  do  not  exist  in  the  mammae,  but  are  formed 
in  the  milk  soon  after  milking.  In  some  breeds,  as  in  those  of  the  ChanneL 
Islands,  this  change  occurs  more  quickly  than  in  others.  Such  breeds,  as  the 
Jersey,  Guernsey,  and  any  others  in  which  intense  inbreeding  has  been  car- 
ried on,  and  in  which  acclimatization  has  not  been  perfected,  should  not 
be  used  for  infants  and  young  children.  These  breeds,  of  course,  do  not 
represent  all  of  those  available  for  substitute  feerling,  for  we  may  mention 
many  others  equally  good  each  in  its  country.  For  example,  the  Kerry, 
of  Ireland ;  the  Red  Polled,  of  England ;  the  Dutch  Belted,  and  the  Flem- 
ish; also,  the  Flamande  and  the  Cotentine,  of  France;  the  Norman  breed, 


COWS'  MILK.  117 

of  N'ormandy;  besides  the  Sirinentbal,  sometimes  called  Bernese,  of  Switz'^r- 
land;  together  with  the  Chianina,  of  Italy,  and  tiie  Allgauer,  of  Germany. 
The  native  cow  of  this  country,  the  "Red  Cow,"  througli  many  generations 
of.  neglec^  and  exposure  in  winter,  lias  undoubtedly  acquired  an  impaired 
digegJ;;Qi3j,  ajid.dpes  not  respond  readily  to  appropriate  changes  of  food. 

.  Care  of  the  Cow.- — Knowing„.th]e  cqw-to.  be  a  sensitive  animal,  she 
should  be  carefully  guarded  from  useless  excitement.  She  should  be  care- 
fully groomed  by  cleaning  and  washing,  arnl  the  parts  should  be  thoroughly 
dried.  The  barn  should  have  plenty  of  fresh  air,  and  the  sunlight  should  be 
admitted.  There  should  be  plenty  of  room  for  exercise.  In  the  stalls  the 
cow  should  have  perfect  freedom  for  her  head  and  limbs.  The  food  a  cow 
receives  should  be  wholesome  and  varied.  She  should  never  be  fed  with  the 
by-products  of  brewery  or  glucose  factories.  The  food  best  adapted  for  the 
cow  is  hay,  wheat,  bran,  ground  oats,  and  commeal.  In  winter  sugar  beets 
and  carrots  may  be  added.  Much  care  is  needed  to  graduate  the  change  from 
green  foods  to  dry,  as  disturbance  of  the  equilibrium  of  the  mammary 
gland  is  followed  by  injuripus  effects  to  the  consumer.  "VVe  should  strive 
to  give  a  cow  green  clover,  green  corn,  green  oats,  and  meadow  grass.  Poi- 
sonous weeds  must  be  guarded  against.  Not  infrequently  we  read  of  gastro- 
enteric conditions  in  children,  which  are  traceable  to  poisonous  weeds.  Pure 
water  in  large  quantities  must  always  he  0.i  hand.  A  cow  is  best  adapted 
for  the  production  of  milk  between  her  third  and  ninth  years.  The  milk 
of  a  cow  is  not  adapted  for  infant  feeding  until  it  is  free  from  colostrum 
corpuscles.    It  should  not  be  used  in  the  advanced  stage  of  pregnancy. 

Tuherculin  Test. — Every  dairy  now  resorts  to  prophylactic  measures; 
hence,  none,  should  be  employed  that  has  not  been  subjected  to  the  tuber- 
culin test.  Besides,  this,  each  cow  should  be  examined  by  a  skilled  veteri- 
narian regarding  her  physical  condition. 

,,  Care  ^pf  the  il/iVL-r— The  .vital  point  consists  in  excluding  germs  and 
barn  filtlj.  The  Mil,k  CommissiQn  of  New  York  has  tentatively  fixed  upon 
a  maximufli  of  30.,.00p  ger^ms  pf^iall,  kinds  per  cubic  centimeter  of  milk.  A 
-.cubic  centimeter  is.about  Qne:half  a.  teaspoonful,  and  a  quart  of  milk  con- 
tains about  900  cubic  centimeters,  so  the  total  number  of  germs  in  a  quart 
must  be  less  than  27,000,000.  .    , ... , . 

_  ,,  ;:,This  standard  must. not  be  exceeded  in  order  to  obtain  the  endorsement 
of;  tlie  Commission,  and  must  be  attained  solely  by  measures  directed  toward 
sc;;upulous  cleanliness,  proper  cooling,  and  prompt  delivery. 

Furthermore,  the  milk  certified  by  the  Commission  must  contain  not 
less  than  4  per  cent,  of  butter  fat,  on  the  average,  and  have  all  other 
characteristics  of  pure,  wholesome  milk. 

,/,,In  order  that  .dealers  who  incur  the  expense  and  take  the  precautions 
necessary, , to.,  tij^riiiish  a  truly  pleanajXjtl  T^ho^ssome  milk  may  have  some  suit- 
able means  of  bringing  these  facts  before  the  public,  the  Commission  offers 


218  NUTRITION. 

them  the  right  to  use  caps  on  their  milk  jars  stamped  with  the  words: 
"Certified  hy  the  Commission  of  the  Medical  Society  of  the  County  of  New 
York:' 

Eowland  G.  Freeman,  answering  an  inquiry  of  mine  concerning  the  pos- 
sibility of  procuring  milk  free  from  germs  in  the  dairy,  says :  "By  means  of 
special  methods  it  has  been  found  possible  in  some  cases  to  obtain  milk 
with  only  10  bacteria  per  cubic  centimeter.  These  methods  are,  however, 
ncft- 'practicable  for  a  large  commercial  supply.  When  the  conditions  at  the 
dairy  are  known  to  be  good  a  bacterial  content  averaging  less  than  5000 
per  cubic  centimeter  has  seemed  to  me  satisfactory^  while  a  bacterial  content 
averaging  less  than  10,000  is  fairly  good." 

Thus  it  appears,  that  with  excellent  care,  as  described  in  the  handling 
of  milk,  with  modern  hygiene,  practically  sterile  milk  can  be  procured  for 
infant  feeding. 

Cektified  Milk  in  New  Yoek. 

The  dairy  rules  of  the  United  States  Department  of  Agriculture  de- 
scribe in  detail  the  caring  and  feeding  of  cattle.  It  was  decided  that  the 
acidity  of  milk  should  not  be  higher  than  0.2  per  cent.,  and  that  the  num- 
ber of  bacteria  should  not  be  more  than  30,000  per  cubic  centimeter. 

The  Rockefeller  Institute  for  Medical  Research  inaugurated  a  periodical 
inspection  of  the  dairies  and  milk  of  the  dealers  who  were  willing  to  co- 
operate to  secure  a  clean,  fresh  milk. 

It  was  observed  that  the  milk  from  a  cow  milked  in  a  dirty  barn  showed 
120,000  bacteria  to  the  cubic  centimeter,  while  another  cow  of  the  same 
herd  milked  in  a  pasture  gave  milk  with  only  26,000.  A  cow  standing  near 
a  pile  of  dry  feed  had  1,000,000  bacteria  per  cubic  centimeter,  while  the 
milk  of  other  cows  had  a  low  bacterial  count.  Dirty  cows  gave  a  much 
higher  count  of  bacteria  than  clean  ones.  Clean  cows  in  a  herd  gave  a  count 
of  2000  as  against  90;000  in  the  milk  of  the  dirty  cows.  The  milker  was 
frequently  found  to  be  dirty,  and  the  milk  from  some  milkers  always  gave 
a  high  bacterial  count.  With  the  utensils  it  was  sometimes  difficult  to  find 
which  factor  was  at  fault.  The  ordinary  strainer  was,  however,  a  prolific 
source  of  bacteria. 

With  a  sterile  pail  and  a  sterilized  cotton  or  cheese-cloth  strainer  the 
bacteria  would  fall  in  numbers.  Aeration  by  requiring  more  complicated 
apparatus  increased  the  danger  of  contamination.  This  was  particularly 
so  if  aeration  was  carried  out  in  a  dirty  barn  or  without  regard  to  strict 
cleanliness. 

The  process  of  rapid  cooling  is  one  of  the  most  important  factors  in 
the  production  of  uncontaminated  milk.  The  cooling  of  milk  in  springs 
is  seldom  sufficient,  as  the  temperature  of  water  in  summer  was  found  to 
vary  from  45°  F.  to  70°  F.,  whereas  the  milk  should  be  brought  below  45°  F. 


THE  ADULTERATION  OF  MILK.  119 

to  insure  few  bacteria.  Ice  is  absolutely  necessary  to  the  farmer  who 
handles  milk.  W.  H.  Park  {Yale  Medical  Journal)  says,  as  to  the  number 
of  bacteria  in  the  city  milk :  "From  an  examination  of  nearly  1000  speci- 
mens there  is  no  question  about  the  enormous  number  of  bacteria  present  in 
the  city  milk.  Now  as  to  the  harmfulness  of  this  milk:  The  group  of  chil- 
dren under  1  year,  on  heated  milk,  received  from  decent  farms,  running 
before  heating  from  1,000,000  to  5,000,000  bacteria  per  cubic  centimeter, 
did  not,  so  far  as  we  could  see,  suffer  any  serious  harm  from  the  bacterial 
products  in  the  milk.  During  the  summer  these  children  had,  off  and  on, 
intestinal  disorders,  but  not  much  more  than  those  in  the  same  section  of 
the  city  receiving  milk  from  the  very  best  possible  dairies  around  Few  York. 
The  children  on  pasteurized  milk  showed  some  very  interesting  results. 

"There  were  very  few  bacteria  in  this  milk  when  first  received — any- 
where from  10,000  to  20,000;  but  on  the  second  day  they  had  so  increased 
as  to  be  from  10,000,000  to  30,000,000.  In  some  cases  where  the 
second  day  milk  was  given  there  was  immediate  vomiting,  followed  by 
diarrhoea. 

"In  the  asylums,  where  the  children  were  from  3  to  13  years  of  age, 
we  found  no  trouble  from  the  milk  during  the  summer  months,  although 
in  some  cases  it  ran  as  high  as  100,000,000  bacteria  per  cubic  centimeter. 

"The  reasons  for  the  enormous  development  of  bacteria  in  the  milk  were 
insufficient  cleanliness  in  getting  the  milk  and  very  faulty  cooling  arrange- 
ments. The  farmers  mostly  put  their  milk  in  springs;  as  the  summer 
advances  the  water  gets  higher  in  temperature  until  it  reaches  about  60°  F. 
Some  farmers  hardly  cool  their  milk  at  all. 

"The  author  has  seen  milk  shipped  in  cans  standing  in  a  car  where 
the  temperature  was  90°  F.,  and  left  there  without  any  ice  for  seven  hours. 
The  City  Health  Board  has  passed  a  rule  that  all  milk  shall  be  at  a 
temperature  of  50°  F.,  or  under,  when  it  reaches  New  York  City." 

The  Adulteration  of  Milk. 

Formaldehyde  in  Milk. — ^The  adulteration  of  milk  by  the  use  of  for- 
maldehyde is  becoming  more  common  than  is  generally  suspected.  For  a 
time  its  use  was  a  "trade  secret,"  but  it  has  been  so  thoroughly  advertised 
that  every  obscure  individual  who  has  a  milk  route  is  now  familiar  with  the 
preservative  qualities  of  formaldehyde.  In  our  large  cities  the  health  officers 
are  J  on  the  watch,  and  hence  in  these  its  use  is  being  curtailed,  but  in  the 
smaller  towns  and  villages  the  people  have  not  this  protection.  It  would 
be  well,  therefore,  for  physicians  to  guard  against  this  and  keep  it  in  mind 
when  mysterious  illness  develops  in  milk-users.  They  should  also  be  pre- 
pared to  make  an  analysis  of  milk  at  any  time  as  to  its  freedom  from  the 
drug.    This  is  a  simple  procedure,  and  yet  one  that  requires  considerable 


130 


NUTRITION. 


technical-  skill  in  the  use  of  some  of  the  tests.  The  Lancet-GUmc  gives  the 
various  methods  for  testing  formaldehyde  as  laid  down  hy  Herman  Harms, 
some  of  which  are  quite  simple : — 

Rimini  Test. — (A)  :  Phenyl-hydrazine  muriate,  0.5  gram;  distilled 
water,  100  cubic  centimeters;  dissolve.  (B)  :  Sodium  nitroprusside,  0.5 
gram;  distilled  water,  30  cubic  centimeters;  dissolve.  (C)  Soda,  TJ.  S.  P., 
15  grams;  distilled  water,  60  cubic  centimeters;  dissolve.  To  15  cubic 
centimeters  of  the  suspected  milk  in  a  test-tube  add  10  drops  of  A,  mix 
and  add  3  drops  of  B;  mix;  and  let  5  drops  of  C  run  in  slowly  on  the  side 
of  the  test-tube.  In  the  presence  of  formaldehyde  a  blue  color  is  instantly 
produced,  changing,  on  standing,  to  red.  On  adding  to  the  mixture  of 
milk  and  solution  A,  2  drops  of  ferric  chloride  solution,  and  then  about  2 
cubic  centimeters  of  concentrated  hydrochloric  acid,  a  red  color  is  pro- 
duced, which  later  changes  to  orange-yellow.  In  sour  milk  the  above-men- 
tioned blue  is  supplanted  by  green.  The  Eimini  test  is  easily  applied,  and 
readily  detects  formaldehyde  when  present  to  the  extent  even  of  1  part 
in  25,000  or  30,000.      . 

■  Phloroglucin  Test. — Dissolve  1  gram  of  phloroglucin  in  100  cubic 
centimeters  of  distilled  water.  Put  10  cubic  centimeters  of  the  suspected 
milk  in  a  test-tube  and  add  5  cubic  centimeters  of  the  phloroglucin  solu- 
tion; shake  and  add  1  cubic  centimeter  of  solution  of  potassa  (U.  S.  P.). 
If  formaldehyde  is  present,  a  red  color  is  developed  at  once,  fading  usu- 
ally within  five  or  ten  minutes ;.  hence  the  color  must  be  observed  at  once. 
One  part  in  20,000  gives  a  decided  reaction. 

Hehner's  Test. — ^To  15  cubic  centimeters  of  concentrated  sulphuric 
acid  in  a  test-tube  add  1  or  2  drops  of  ferric  chloride  test  solution  (U.  S.  P.) 
and  mix.  Then  pour  upon  this,  in  such  manner  as  not  to  mix  the  layers, 
the  suspected  milk.  A  violet  color  indicates  the  presence  of  formaldehyde. 
In  the  case  of  cream  dilute  the  cream  with  an  equal  volume  of  water,  and 
then  apply  the  test  as  above  described.  The  violet  color  is  sometimes  pro- 
duced at  once,  but  oftener  not  for  five  or  ten  minutes,  and  sometimes  not 
for  an  hour  or  so,  depending  on  the  amount  of  formaldehyde  present.  By 
this  test  1  part  in  10,000  or  15,000  is  readily  detected. 
;-  ,  Liehermann  Phenol  Test. — In  the  presence  of  small  traces  of  for- 
maldehyde, distill  off  from  the  milk  a  few  cubic  centimeters,  and  add  to 
this  1  drop  of  very  dilute  aqueous  phenol  solution.  Then  pour  this  mix- 
ture slowly  upon  concentrated  sulphuric  acid  in  a  test-tube  solution  so  as 
to  form  a  layer.  A  bright  crimson  color  appears  at  the  zone  of  contact. 
This  is  easily  seen  in  as  little  as  1  part  in  200,000,  and  in  greater  propor- 
tion in  1  to  100,000.  There  is  a  milky  zone  above  the  red  color,  and,  if 
more  concentrated,  there  will  be  a  whitish  or  pinkish  precipitate.  Some- 
times the  zone  will  appear  in  about  one  hour,  one-tenth  of  an  inch  below 
the  line  of  contact. 


MILK  PRESERVATIVES. 


121 


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122  NUTRITION. 

HydrocTiloric  Test. — Fifteen  or  20  cubic  centimeters  of  suspected  milk, 
together  with  2  or  3  cubic  centimeters  of  strong  hydrochloric  acid,  are 
boiled  for  a  few  minutes  in  a  test-tube.  A  red  coloration  indicates  for- 
maldehyde. Other  tests  are  known,  but  they  are  more  complicated  and 
require  apparatus  or  reagents  not  kept  by  the  average  pharmacist.  The 
above  tests  are  all  simple  in  their  application  and  afford  a  ready  means  of 
detecting  formaldehyde  in  milk  and  cream. 

The  Eimini  test  is  highly  recommendable.  The  reaction  in  sweet  milk 
appears  rapidly  and"  with  certainty.  Hehner's  test,  as  well  as  the  phloro- 
glucin  and  phenol  tests,  are  very  reliable  and  are  all  extremely  sensitive. 
The  hydrochloric  acid  test  is  very  simple,  but  is  not  to  be  depended  on;  it 
may  show  formaldehyde  in  most  instances;  however,  cases  have  come  under 
our  observation  when  it  has  utterly  failed  to  show  the  reaction,  probably 
because  of  the  milk  having  undergone  some  unknown  changes.  The  Lie- 
bermann  test  is  simple,  delicate,  and  shows  formaldehyde  very  readily. 

As  corroborative  evidence,  it  is  well,  after  the  tests  are  finished,  to 
let  the  suspected  milk  or  cream  stand  in  a  warm  place  for  twenty-four 
hours,  A  pure  sample  will  invariably  turn  sour  and  separate.  A  sample 
which  has  been  "doctored"  with  formaldehyde,  however,  will  show,  at  the 
end  of  twenty-four  hours,  but  a  very  slight  separation,  if  indeed  any  at 
all,  and  will  have  but  a  slight  odor. 

It  is  desirable  that  all  test  solutions  be  freshly  prepared,  especially  the 
nitroprusside  of  sodium  solution  in  the  Eimini  test,  and  that  the  suspected 
sample  be  as  fresh  as  possible.  Sour  samples  are  difficult  to  test,  and  may 
yield  variable  results,  because  in  these  formaldehyde  has  been  oxidized,  and 
is  no  longer  present  as  formaldehyde.  In  carrying  out  the  tests  for  for- 
maldehyde it  is  advisable  to  work  the  suspected  sample  and  the  one  known 
to  be  pure  side  by  side.  Finally,  do  not  expose  your  tests  or  have  your  milk 
placed  where  a  bottle  of  formaldehyde  is  being  opened,  for  the  vapor  is  very 
penetrating,  and  you  thus  may  be  easily  led  to  misleading  results.  When 
formaldehyde  has  been  found  to  be  present  by  at  least  three  of  the  afore- 
mentioned tests,  it  may  be  considered  that  its  presence  has  been  shown. 

'  Tuberculous  Infection  Through  Milk. 

The  question  of  tuberculous  infection  by  ingestion  of  milk  is  answered 
in  the  negative  by  N.  Aspe  (Rev.  d.  Med.  y  Cir.  Prac,  Nov.  21,  1901).  If 
the  tubercle  bacillus  reaches  the  cow's  udder,  it  must  necessarily  be  carried 
thither  by  the  blood.  The  bacillus  has  yet  to  be  found  in  the  blood;  but, 
supposing  its  presence  there,  we  are  taught  to  believe  that  every  gland  in 
the  body,  by  its  selective  power,  takes  from  the  blood  only  those  elements 
which  are  necessary  to  the  elaboration  of  its  peculiar  products.  This  would 
seem  to  dispose  of  the  possibility  of  infection  of  the  milk  before  it  leaves 


TUBERCLE  BACILLI    IX   MILK.  123 

the  cow's  body,  unless  the  elective  faculty,  attributed  to  other  glands,  be 
denied  to  the  mammary.  Granting  this  possibility,  if  we  recall  that  in  the 
production  of  experimental  infections  by  subcutaneous  inoculation  the  first 
organs  to  be  affected  are  the  lymphatics,  it  is  natural  to  suppose  that  the 
first  and  invariable  effect  of  the  ingestion  of  tuberculous  milk  would  be  the 
development  of  tabes  mesentcrica,  yet  primary  tabes  is  comparatively  rare. 
The  author  of  this  paper  further  raises  the  question  of  identity  between  the- 
human  and  bovine  tubercle  bacillus,  and  quotes  experiments  in  inoculation 
of  cows  with  cultures  from  human  tuberculous  products  with  negative  results 
in  the  nineteen  animals  experimented  upon,  whereas  animals  injected  with 
the  bovine  form  quickly  succumbed,  and  autopsy  showed  tuberculous  lesions. 

The  Influence  cf  High  Temperature  on  Tubercle  Bacilli  in  Milk. — 
Barthel  and  Stenstrom  {CcntialhJt.  f.  Baht.,  October  8,  1901),  in  reviewing 
recorded  experiments  on  the  sterilization  of  tuberculous  milk,  remark  on  the 
very  variable  results  obtained  by  different  observers.  Bang  has  stated  that 
heating  tuberculous  milk  to  80°  C.  is  not  sufficient  to  kill  the  bacilli,  but 
that  a  temperature  of  85°  C.  is  sufficient  for  the  purpose.  Forster  has  found 
70°  C.  for  five  to  ten  minutes  capable  of  killing  the  organisms;  de  Man,  70° 
C.  for  ten  minutes,  and  80°  C.  for  five  minutes.  Galtier  has  shown  that  milk 
submitted  to  70°,  75°,  80°,  and  85°  C.  for  six  minutes  is  still  capable  of 
conveying  infection,  and  others  have  had  similar  results.  Barthel  and  Stens- 
trom have  conducted  experiments  which  go  to  shoiv  tliat  the  chemical  reac- 
tion of  the  milTc  has  much  to  do  with  the  facility  with  irhich  it  is  sterilized. 
The  material  was  obtained  from  a  cow  with  an  udder  in  an  advanced  state  of 
tuberculosis.  Guinea-pigs  were  used  to  test  the  results,  and  the  effect  of 
65°,  70°,  75°,  and  80°  C.  was  studied.  The  results  were  positive  in  all 
cases;  that  is  to  say,  a  temperature  of  80°  C.  for  ten  minutes,  a  temperature 
of  75°  C.  for  fifteen  minutes,  70°  C.  for  fifteen  minutes,  and  65°  C.  for 
twenty  minutes  were  all  incapable  of  sterilizing  the  milk.  These  results 
the  authors  interpret  as  follows :  Storch  has  shown  that  the  chemical 
changes  in  milk  are  the  more  marked  the  more  advanced  the  disease  of  the 
udder,  and  that  the  reaction  becomes  more  and  more  markedly  alkaline. 
On  the  other  hand,  it  has  long  been  known  that  it  is  more  difficult  to  sterilize 
an  alkaline  than  a  neutral,  and  a  neutral  than  an  acid  fluid.  The  specimen 
with  which  they  worked  was  strongly  alkaline,  and  to  this  they  ascribe  the 
difficulties  in  its  sterilization.  Variations  in  chemical  reaction  explain,  in 
their  opinion,  the  variations  in  the  results  obtained  by  other  investigators. 

The  Tuberculin  Test  of  Pure-bred  Cattle.— Mr.  D.  E.  Salmon,  D.  Y.  M., 
Chief  of  the  Bureau  of  Animal  Industry  of  the  United  States  Department 
of  Agriculture,  has  recently  issued  a  pamphlet  in  which  he  demonstrates  the 
necessity  of  guarding  against  the  importation  of  disease  by  means  of  cattle, 
and  upholds  the  present  regulations  to  prevent  such  occurrences  as  proper 
and  consistent.     The  chief  danger  to  cattle  arises  from  the  prevalence  of 


124:  NUTRITION. 

tuberculosis,  which  disease  affects  herds  more  widely  and  more  disastrously 
than  any  other. 

Even  if  the  point  urged  by  Professor  Koch  at  the  British  Congress  on 
Tuberculosis  be  granted,  and  it  is  allowed  that  the  spread  of  tuberculosis  by 
milk  and  meat  is  to  be  feared  but  to  a  slight  extent,  the  fact  must  still  be 
borne  in  mind  that  tuberculosis,  in  itself,  is  a  decimating  factor  among 
cattle  of  immense  importance. 

Mr.  Salmon  shows  that  the  United  States  has  a  very  large  export  trade 
in  cattle,  and  one  that  is  continually  increasing.  He  further  points  out  that 
rigid  restrictions  are  in  force  in  many  countries  in  the  world  to  prevent 
tuberculous  beasts  from  gaining  an  entrance  into  those  territories;  conse- 
quently, if  we  wish  our  cattle  to  enter  those  markets,  they  must  not  only  be 
free  from  tuberculosis  when  they  leave  the  farm,  but  also  when  they  arrive 
in  a  foreign  country.  To  effect  this  object,  every  effort  must  be  put  forth 
to  keep  out  tuberculous  cattle  from  this  country,  for  a.  few  thus  diseased  will 
quickly  spread  contagion. 

The  argument  is  therefore  advanced  that  the  tuberculin  test  as  now 
adopted  must  be  strictly  enforced  to  guard  against  such  a  result.  The  con- 
tention is  likewise  made  that  the  pure-bred  cattle  mainly  imported  from 
Great  Britain  are  the  chief  menace  in  this  respect,  and  that,  if  the  tuber- 
culin test  were  not  strictly  adhered  to,  the  blue-blooded  immigrants  from 
the  United  Kingdom  would  disseminate  the  germs  of  tuberculosis  among 
cattle  from  one  end  of  the  country  to  the  other. 

Tubercle  Bacilli  Disseminated  by  Cows  in  Coughing,  as  a  Possible 
Source  of  Contagion. — The  general  belief  at  the  present  time  that  the  means 
by  which  tuberculosis  is  chiefly  disseminated,  by  the  inhalation  of  dried 
tuberculosis  sputum  which  becomes  pulverized  and  is  carried  about  by  cur- 
rents of  air,  or  put  into  motion  in  other  ways,  has  been  strongly  substan- 
tiated by  numerous  experiments.  Fliigge,  however,  is  not  in  accord  with 
these  views,  and  is  of  the  opinion  that  the  spread  of  tuberculosis  -is  due 
mainly  to  the  inhalation  of  minute  particles  of  sputum  which  the  act  of 
coughing  thus  ejects.  He  further  holds  that  these  particles  float  in  the 
air  for  a  considerable  period  of  time,  and  may  be  blown  hither  and  thither 
by  very  slight  currents.  Klebs,  in  this  country,  has  demonstrated  the  fact 
that,  during  the  act  of  coughing,  minute  particles  of  sputum,  often'  con- 
taining tubercle  bacilli,  are  thrown  out.  At  his  instance,  too,  Curry,  of 
Boston  (Boston  Medical  and  Surgical  Journal,  October^  1898,' vol.  cxxxix, 
No.  15),  carried  out  a  series  of  elaborate  experiments  with  the  object  of 
thoroughly  investigating  the  matter. 

Dr.  Curry  concluded  from  his  experiments  that,  although  there  is  a 
possible,  and  even  a  probable,  danger  from  this  source,  Pliigge  has  greatly 
exaggerated  this  danger.  Dr.  Mazyck,  lecturer  and  demonstrator  of  bac- 
teriology, Veterinary  Department,  University  of  Pennsylvania,  has  been  led 


TUBERCULorS  INFECTION  THROUGH  MILK.  125 

to  luideitako  oxperiinenls  to  ?ee  if  it  were  not  possible  tliat  cows  in  the  act 
of  coughing  would  likewise  expel  small  particles  of  tuberculous  material 
rich  in  tubercle  bacilli.  The  results  of  these  studies  were  made  the  subject 
of  a  paper  by  Dr.  ^Maz^ck,  which  was  read  before  the  Pathological  Society 
of  Philadelphia  on  November  8,  1900.  The  belief  is  common  that  cows 
when  coughing  swallow  all  their  sputum,  and  do  not  project  it  to  any  extent. 
Dr.  Mazyck,  by  ingenious  methods  devised  by  himself,  has  disproved  this 
theory,  and  has  practically  demonstrated  that,  in  the  act  of  coughing,  cows, 
as  well  as  men,  atomize,  ?o  to  speak,  their  sputum,  and  project  it  into  the  air 
in  minute  particles,  which  may  float  for  some  time.  Inoculation  of  guinea- 
pigs  with  this  secretion  gave  a  considerable  proportion  of  positive  results. 
Dr.  Mazyck  came  to  the  conclusion  that  the  danger  of  infection  by  means 
of  this  atomized  sputum,  as  far  as  mankind  goes,  is  confined  practically  to 
those  in  constant  contact  with  the  animals,  but  for  other  animals  in  the 
same  stable  the  infected  animals  must  be  considered  a  source  of  danger. 
The  moral  to  be  derived  from  the  outcome  of  Dr.  Mazyck's  experiments 
would  seem  to  be  that  when  tuberculosis  is  diagnosed  in  a  cow  she  should 
be  isolated  as  far  as  is  possible;  at  any  rate,  she  should  not  be  confined  in 
a  shed  with  healthy  animals. 

Sterilization  and  Pasteurization  vs.  Tubercle-free  Herds,  etc.^ — The 
comparative  dependence  upon  sterilization  or  pasteurization  and  the  insur- 
ance of  absolute  absence  of  tubercle  in  herds  supplying  milk  are  discussed 
by  Hope,  who  thinks  that,  while  raw  milk  is  especially  liable  to  contamina- 
tion, sterilization,  valuable  as  it  is,  is,  after  all,  only  an  expedient,  and  must 
not  be  put  in  such  prominence  that  the  importance  of  the  other  safeguards 
of  absolute  cleanliness  of  source  and  handling  are  neglected.  Beyond  any 
question,  he  says,  the  ultimate  advantage  lies  in  obtaining  the  milk  from 
herds  free  from  tuberculosis.  A  comparison  is  made  with  having  water 
from  a  contaminated  source  and  making  it  pure  later  by  chemical  processes 
or  boiling  it,  and  obtaining  it  in  the  first  place  from  an  uncontaminated 
source.  He  thinks  it  is  quite  possible  to  insure  that  the  milk  supply  shall 
come  from  cows  free  from  tuberculosis. 

The  State  Veterinarian  of  Pennsylvania,  Dr.  Pearson,  thinks  that  not 
over  2  per  cent,  of  the  cattle  of  that  State  are  tuberculous,  and  probably 
if  a  general  test  of  all  the  cattle  of  the  other  States  mentioned  were  made 
we  should  find  a  very  much  smaller  proportion  tuberculous  than  is  indicated 
l)y  this  tabular  statement.  The  explanation  of  the  high  percentages  that 
have  been  given  is  found  in  the  fact  that  it  has  been,  for  the  most  part, 
suspected  herds  which  have  been  tested.  Admitting  that  the  greater  part 
of  these  percentages  are  too  high,  Ave  still  have  revealed  a  condition  which 
is  worthv  of  our  serious  consideration. 


'E.  W.  Hope   (The  Lancet). 


126 


isrUTRITION. 


The  classes  of  animals  most  affected  are  breeding  animals  and  dairy- 
stock.  The  beef  cattle  coming  to  our  markets  are  still  singularly  free  from 
tuberculosis.  Of  4,841,166  cattle  slaughtered  in  the  year  1900  under  Fed- 
eral inspection,  but  5279,  or  0.11  per  cent.,  were  sufficiently  affected  to  cause 
the  condemnation  of  any  part  of  the  carcass.  Of  23,336,884  hogs  similarly 
inspected,  5440  were  sufficiently  affected  to  cause  condemnation  of  some  part 
of  the  carcass.  This  is  equal  to  0.023  per  cent.,  or  slightly  more  than  one- 
fifth  the  proportion  found  in  beef  cattle.  It  is  scarcely  necessary  to  add  that 
there  are  certain  lots  of  cattle  and  hogs  encountered  which  are  affected  in 
much  greater  proportion  than  the  general  average  Just  given. 

From  a  recent  view  by  Drs.  Eussell  and  Hastings,  of  the  Wisconsin 
Agricultural  Experiment  Station,^  of  the  tests  of  cattle  for  tuherculoms 
made  in  the  United  States,  the  following  summary  is  presented : — ■ 

Table  No.  19. 


Vermont 

Massachusetts    

Massachusetts,   entire   herds    

Connecticut     

New  York,   1894    

New   York,    1897-98 

Pennsylvania 

New   Jersey    

Illinois,    1897-98    

Illinois,   1899    

Michigan     

Minnesota     

Iowa 

Wisconsin — 

Experiment  Station  tests: 

Suspected    herds    

Non-suspected    herds    

State  Veterinarian's  tests: 

Suspected   herds    

Tests  of  local  veterinarians  under 
State  Veterinarian  on  cattle  in- 
tended for  shipment  to  States 
requiring  tuberculin  certificate   . 


Number 
Tested. 


60,000 
24,685 

4,093 

6,300 
947 

1,200 

34,000 

22,500 

929 

3,655 

3,430 

873 


323 
935 

588 


3,421 


Number 
Tuberculosis. 


2,390 

12,443 

1,080 

66 

163 

4,800 


560 


122 


115 

84 


191 


76 


Per  cent. 
Tuberculosis. 


3.9 
50.0 
26.4 
14.2 

6.9 
18.4 
14.1 
21.4 
12.0 
15.32 
13.0 
11.1 
13.8 


35.6 
9.0 

32.5 


2.2 


The  following  suggestions,  adapted  from  the  fifty  dairy  rules  of  the 
United  States  Department  of  Agriculture,  are  recommended  for  strict  adop- 
tion in  our  dairies : — 

The  Stable. — Keep  dairy  cattle  in  a  room  or  building  by  themselves. 
It  is  preferable,  when  possible,  to  have  no  cellar  below  and  no  storage  loft 
above.  The  stables  should  be  well  ventilated,  lighted,  and  drained;  should 
have  tight  floors  and  walls  and  plainly  constructed.  Store  the  manure  under 
cover  outside  the  cow  stable,  and  remove  it  to  a  distance  as  often  as  prac- 


^  Bulletin  No.  84,  Wisconsin  Agricultural  Experiment  Station,  March,  1901. 


CARE  OF  THE  MILK.  127 

ticable.  Whitewash  tlie  stables  once  or  twice  a  year;  use  land  plaster  ill 
the  manure  gutters  daily.  Clean  and  thoroughly  air  the  stable  before  milk- 
ing; in  hot  weather  sprinkle  the  floor. 

The  Cows. — Have  the  herd  examined  at  least  twice  a  year  by  a  skilled 
veterinarian.  Promptly  remove  from  the  herd  any  animal  suspected  of 
being  in  bad  health  and  reject  her  milk.  Xever  add  an  animal  to  the  herd 
until  certain  it  is  free  from  disease,  especially  tuberculosis.  Do  not  allow 
the  cows  to  he  excited  by  hard  driving,  abuse,  loud  talking,  or  any  unneces- 
sary disturl)ance.  Feed  liberally,  and  use  only  fresh,  i)alatable  food  stuffs. 
Provide  water  in  abundance,  easy  of  access,  and  always  pure.  Do  not  allow 
any  strongly  flavored  food,  like  garlic,  cabbage,  turnips,  to  be  eaten  except 
immediately  after  milking.  Clean  the  entire  body  of  the  cow  daily.  If  the 
hair  in  the  region  of  the  udder  is  not  easily  kept  clean,  it  should  be  clipped. 
If  the  sides  of  the  cow  are  plastered  with  dirt  or  manure,  as  is  often  the 
case,  a  certain  amount  is  sure  to  fall  into  the  pail  of  milk.  This  is  where 
the  trouble  really  begins,  for  this  dirt  and  manure  abound  in  bacteria  which 
cause  decomposition  in  milk,  and  thereby  induce  bowel  disturbances. 

The  Milk. — The  milker  should  be  clean  in  all  respects.  He  should  wash 
and  dry  his  hands  and  clean  his  nails  just  before  milking.  After  the  hands 
have  been  washed,  a  little  vaseline  may  be  used  on  them,  thereby  preventing 
scales  from  the  teat  or  fingers  getting  into  the  milk.  The  milker  should 
wear  clean,  dry  garments,  used  only  when  milking,  and  kept  in  a  clean  place 
at  other  times.  Brush  the  udder  and  surrounding  parts  just  before  milking, 
and  wipe  them  with  a  clean,  damp  cloth  or  sponge.  Commence  milking  at 
the  same  hour  every  morning  and  evening,  and  milk  quietly  and  thoroughly. 
Throw  away  (but  not  on  the  floor — ^better  in  the  gutter)  the  first  few  streams 
from  each  teat.  This  first  milk  is  watery  and  of  little  value,  and  during 
the  intervals  between  milking,  the  bacteria  from  the  air  get  into  the  cow's 
teats  and  grow  with  great  rapidity.  These  bacteria  cause  early  souring  of  the 
milk.  If  in  any  milking  a  part  of  the  milk  is  bloody  or  stringy  or  im- 
natural  in  appearance,  the  whole  mass  should  be  rejected.  Milk  with  dry 
hands,  or  oiled  as  above ;  never  allow  the  hands  to  come  in  contact  Avith  the 
milk.  If  any  accident  occurs  by  which  the  pail,  full  or  partly  full,  of  milk 
becomes  dirty,  do  not  try  to  remove  this  by  straining,  but  reject  all  this 
milk  and  rinse  the  pail. 

Care  of  the  Milk. — ^Eemove  the  milk  of  every  cow  from  the  dairy  at 
once  to  a  clean,  dry  room,  where  the  air  is  pure  and  sweet.  Do  not  allow 
cans  to  remain  in  stables  while  they  are  being  filled.  Strain  the  milk  through 
a  metal  gauze  and  a  flannel  cloth,  or  layer  of  cotton,  as  soon  as  it  is  drawn. 
Aerate  and  cool  the  milk  as  soon  as  strained.  The  rapid  aeration  and  cooling 
of  milk  are  matters  of  great  importance.  Combined  aerators  and  coolers, 
suitable  for  use  with  well  water  or  ice  water,  can  be  had  at  any  dairy  supply 
house  at  a  small  cost.    By  using  one  of  these,  the  cow  odor,  the  animal  heat, 


128  NUTRITION. 

and  much  of  the  dirt  can  be  removed  from  milk  in  a  few  minutes.  The  milk 
should  be  cooled  to  45°  F.,  if  for  shipment,  or  to  60°  ¥.,  if  for  home  use  or 
delivery  to  a  factory.  Never  mix  fresh,  warm  milk  with  that  which  has 
been  cooled.  Do  not  allow  the  milk  to  freeze.  When  cans  are  hauled  a  dis- 
tance they  should  be  full  and  carried  in  a  spring  wagon.  In  hot  weather 
cover  the  cans,  when  moved  in  a  wagon,  with  a  clean,  wet  blanket  or  canvas. 
If  milk  is  stored,  it  should  be  held  in  tanks  of  fresh,  cold  water,  renewed 
daily,  in  a  clean,  cold,  dry  room.  Clean  all  dairy  utensils  by  first  thoroughly 
rinsing  them  in  warm  water;  then  clean  inside  and  out  with  a  brush  and 
hot  water  into  which  a  cleansing  material  is  dissolved ;  then  rinse,  and  lastly 
sterilize  by  boiling  water  or  steam.  Use  pure  water  only.  After  cleaning, 
keep  the  utensils  inverted  in  pure  air  and  sun  if  possible,  until  wanted  for 
use.  Old  cans,  in  which  parts  of  the  tin  are  worn  off,  or  where  there  are 
seams  and  cracks,  are  impossible  to  keep  clean,  and  should  not  be  employed. 

Small  Animals. — -Cats  and  dogs  must  not  be  in  the  stables  during  the 
time  of  milking.  The  reason  for  this  is  that  cats  are  peculiarly  liable  to 
transmit  diphtheria;  both  cats  and  dogs  have  disgusting  skin  diseases  which 
may  be  transmitted  to  children,  and  both  animals  also  are  apt  to  nose 
around  and  dirty  the  utensils. 

if  precautions  like  the  above  are  strictly  carried  out,  the  milk  will  be 
clean  and  remain  fresh  for  a  considerable  length  of  time.  The  fresher  the 
milk  is,  the  better  it  will  be  for  family  use.  The  test  for  uncleanliness  con- 
sists in  an  increase  in  the  proportion  of  lactic  add  generated  in  the  milk, 
and  in  a  large  increase  in  the  number  of  bacteria  per  cubic  centimeter. 

The  New  York  Senate  passed  a  bill  recently,  forbidding  sale  of  milk 
containing  formaldehyde  or  salicylic  acid,  owing  to  their  injurious  effects  on 
infants. 

Eaw  Milk. 

Monrad  {Jahrbuch  f.  KinderheilTcunde,  No.  55,  p.  61)  describes  a 
series  of  children  fed  with  raw  milk.  These  infants  could  not  digest  ster- 
ilized or  boiled  milk.  Their  condition  improved  when  raw  milk  was  sub- 
stituted. It  was  interesting  to  note  that  during  the  course  of  Monrad's 
investigations  an  infant  received  sterilized  milk  by  mistake,  and  its  former 
dyspeptic  symptoms  reappeared. 

Jensen  found  that  new-born  calves  assimilated  raw  milk,  but  when 
boiled  milk  was  given,  they  were  subject  to  coli-enteritis.  Such  calves  that 
recovered  were  atrophic.  Milk,  when  subjected  to  prolonged  sterilization, 
such  as  tyndalizing  the  milk,  undergoes  certain  chemical  changes.  These 
are: — 

1.  Nuclein  and  lecithin  are  rendered  insoluble. 

2.  Milk-sugar  is  completely  changed. 

3.  The  coagulability  of  the  casein  is  impaired. 

4.  The  fat  globules  are  separated  and  rise  to  the  surface  of  the  milk. 


RAW  MILK.  129 

5.  By  tlie  influence  oC  tlie  clilorides  oa  tlie  casein  ])0|)t(nies  are  foi-nied 
in  the  milk. 

G.  The  milk  is  rendered  unpalatable  by  this  superheating. 

7.  The  albumin  is  rendered  much  le?s  assimilable  by  prolonged  heating. 

The  increased  number  of  cases  of  rickets  and  Barlow's  disease  since  the 
advent  of  sterilization  does  not  speak  well  for  this  process. 

Certain  factors  should  be  noted  : — 

1.  That  stei'ilization  is  intended  to  kill  pathogenic  l)acteria  in  the 
milk. 

2.  That  not  only  are  ])athogenic  bacteria  destroyed,  but  also  sapro- 
pliytes,  which  certainly  have  ?ome  bearing  on  the  digestive  functions  of  an 
infant. 

We  know  that  the  proteolytic  bacteria  are  in  the  milk  for  certain 
reasons : — 

1.  To  coagulate  the  casein. 

2.  To  peptonize  this  coagulated  casein. 

It  is  possible  that  by  sterilizing  milk  and  destroying  these  bacteria,  Ave 
rob  the  milk  of  microbes  necessary  to  perform  certain  aids  in  the  digestive 
process. 

Such  assistance  in  the  digestion  of  milk  may  not  be  necessary  in  the 
rol)ust  and  normal  infant,  but  it  is  quite  different  when  we  are  dealing  with 
dyspeptic  or  atrophic  infants. 

When  infants  ilirive  on  sterilized  mill-,  then  it  is  a  good  plan  to  con- 
tinue the  mme;  but  if  dyspeptic  symptoms — vomiting  and  undigested,  cheesy 
stools  with  colicky  symptoms — show  themselves,  then  such  food  should  be 
discontinued.  Such  cases  demand  a  radical  change  of  diet,  and  it  is  here 
that  an  easily  assimilated  form  of  food  is  indicated.    Such  food  is  raw  milk. 

Scorbutic  cases  in  which  we  continue  giving  sterilized  milk  will  not  be 
modified  whether  we  add  HCl,  pepsin,  or  alkalies.  The  character  of  the 
food  is  at  fault  and  a  radical  change  must  be  made.  For  the  treatment  of 
atropliy  nothing  will  supersede  raw  milk.  Certain  precautions  must' be  taken 
in  securing  raw  milk  for  infant  feeding. 

The  ideal  cows'  milk  is  clean,  raw  milk.  By  this  is  meant  milk  free 
from  all  possible  contamination.  Such  milk  should  be  obtained  from  a 
stable  having  all  modern  hygienic  surroundings.  If  greater  attention  were 
l)estowed  on  the  condition  of  the  cow,  the  cow's  udder,  the  stable,  the 
l)ucket,  the  hands  of  the  milker,  then  less  sterilization  and  pasteurization 
would  be  necessary.  Let  it  be  distinctly  understood  that  certain  chemical 
changes  are  brought  about  in  milk  when  it  is  steamed,  he  it  in  the 
process  of  sterilization  «r  pasteurization.  Neither  sterilization  nor  pasteur- 
ization adds  to  the  digestibility  of  milk.  Indeed,  chemical  experience  has 
demonstrated  the  fact  that  raw  milk,  sold  in  some  places  as  certified  milk, 
in  the  Walker-Gordon  milk  laboratories  as  guaranteed  milk,  is  more  easily 

0 


130 


NUTRITION. 


assimilated.  It  is  jDroven  by  the  condition  of  the  stools  as  well  as  the  gas- 
tric digestion. 

Nature  has  given  us  a  good  example  of  how  milk  should  be  fed  to  an 
infant.  Breast-milk  is  certainly  raiv  milk,  and  is  served  to  the  infant  at 
the  temperature  of  the  body.  N"ot  only  does  boiling  and  steaming  of  milk 
produce  chemical  changes  in  the  albuminoids,  but  it  renders  the  process  of 
digestion  much  more  difficult,  and  thus  it  is  that  most  infants  taking  boiled 
milk  suffer  with  constipation.  This  is  not  so,  however,  in  the  case  of  infants 
fed  on  raAv  milk. 

When  sterilized  and  pasteurized  milks  are  found  to  disagree  with  chil- 
dren, raw  milk  may  sometimes  be  easily  assimilated.  Thus  it  will  be  found 
that,  while  boiled  milk,  or  sterilized  or  pasteurized  milk,  given  either  whole 
or  with  its  proper  dilution  to  suit  the  various  ages,  will  provoke  constipa- 
tion, by  substituting  raw  milk  for  heated  milk  the  same  will  be  more  easily 
assimilated.  The  author  has  frequently  noted  decided  antiscorbutic  prop- 
erties in  fresh  raw  milk.  In  children  with  pronounced  rickets,  and  even 
scurv}^,  the  withdrawal  of  sterilized  or  other  milk  and  the  substituting  of 
fresh  raw  milk  will  work  surjjrising  changes. 

Biedert^  states  that  he  has  followed  Escherich  and  Epstein,  who  rec- 
ommend giving  full  milk  to  children  at  birth.  In  France,  Budin  and  H. 
de  Eothschild,  and  more  recently  E.  Schlesinger,  in  German}^,  have  given 
undiluted  milk  to  both  sick  and  well  children  as  a  substitute  for  breast- 
milk.  Biedert  claims  to  have  seen  good  results  in  some  instances,  but 
cannot  recommend  whole  milk,  as  a  rule,  for  feeding  children.  Marfan, 
another  advocate  of  pure-milk  feeding,  believes  that  milk  should  be  diluted 
until  the  fourth  or  fifth  month,  but  later  he  advises  pure-milk  feeding. 
Schlesinger,  of  Breslau,  while  giving  pure  milk,  gives  a  longer  interval 
between  the  meals.  That  the  greatest  possible  success  is  not  achieved 
by  this  method  in  France  can  be  judged  by  the  statement  of  Marfan 
while  discussing  the  subject  of  athrepsia.  He  says:  ''N'a  jamais  vu 
VatUrepsie  confirmee  se  terminer  favorahlement/'  Thus  it  seems  that  even 
we  have  much  better  results  than  the  French,  for  there  are  certainly  a  great 
many  children  who  can  and  will  digest  a  diluted  milk,  and  thin  milk-and- 
.  cream  mixtures,  as  shown  by  their  stool,  their  sleep,  and  their  increase  in 
weight.  These  same  children  with  enfeebled  digestive  functions  will  in- 
variably show  gastric  disturbances — such  as  vomiting,  colic,  constipation,  or 
diarrhffia,  restlessness,  sleeplessness — and  will  cry  continually  Mdien  given 
whole  milk.  So  that  tvhole-milk  feeding  is  not  assimilated  during  the  early 
months  of  a  child's  life;  besides  they  do  not  increase  in  weight.  This 
method  of  feeding  has  been  tried  over  and  over  again^  and  we  are  compelled 
to  discontinue  the  heavier  food,  consisting  of  whole  milk,  and  substitute  a 
light  food,  consisting  of  dihitod  milk. 


*  Fourth  Edition  of  Kindcrorniilirung,  1000,  page  184. 


RAW  MILK.  1;}1 

Fresh  Raw  Milk. — Just  as  the  medical  profession,  and  to  some  extent 
the  laity,  liave  boconie  hiipresscd  with  the  idea  that  milk  should  be  boiled 
before  being  used,  to  iii-sui-e  the  destruction  of  the  microbes  which  it  contains, 
Dr.  Freudenrich  comes  fonvard  with  a  series  of  experiments,  by  which 
he  claims  to  ])rove  tliat  raw  milk  possesses  remarkable  germicidal  proper- 
ties. According  to  liis  experiments,  the  bacillus  of  cholera,  when  put 
■into  fresh  cows'  milk,  dies  in  one  hour,  the  bacillus  of  typhoid  fever  suc- 
cumbs at  the  end  of  twenty-four  hours,  while  other  germs  die  at  the  end 
of  varying  periods. 

Milk  which  has  been  exposed  to  a  temperature  of  131°  F.  loses  its 
germicidal  properties.  Milk  which  is  four  or  five  days  old  is  also  devoid  of 
microbe-killing  power. ^ 

Undiluted  Milk  as  a  Food  for  Infants. — Xotwithstanding  tireless  re- 
search and  wonderful  ingenuity,  a  perfect  substitute  to  replace  mother's 
milk  as  an  article  of  food  for  the  nourishment  of  infants  3-et  remains  to  be 
discovered.  This  is  greatly  to  be  regretted,  as  the  occasions  are  not  rare  on 
wdiich  mother's  milk  is  not  available,  or  it  is  desirable  or  even  necessary 
to  have  recourse  to  such  a  substitute.  The  fact  is  that  there  is  yet  not  a 
little  to  learn  concerning  the  assimilative  processes  in  children,  and  knowl- 
edge, particularly  of  a  practical  character,  concerning  food  is  not  so  exten- 
sive or  so  precise  as  it  might  be.  As  K.  Oppenheimer  points  out  in  a  recent 
communication,  an  article  of  food  for  the  infant  to  serve  as  a  perfect  sub- 
stitute for  mother's  milk  should  be  as  useful  as  the  latter  in  the  nourish- 
ment both  of  healthy  children  and  of  those  suffering  from  gastro-intestinal 
catarrh.  These  requirements,  however,  are  not  met  by  any  of  the  large 
number  of  artificial  foods  that  have  been  devised.  For  the  purpose  of  estab- 
lishing the  usefulness  of  undiluted  cows'  milk  as  judged  by  this  standard, 
Oppenheimer  made  comparative  observations  in  normal  healthy  children, 
in  infants  suffering  from  gastro-intestinal  derangement,  and  in  atrophic 
children.  In  almost  all  of  the  11  cases  of  the  first  group  the  body  weight 
exhibited  a  steady  and  uniform  increase,  while  of  36  cases  of  the  second 
group  only  6  failed  to  do  well,  and  of  12  cases  exhibiting  marked  atrophy 
8  failed  to  do  well.  All  of  the  foregoing  cases  were  under  observation  for 
periods  of  more  than  four  weeks.  Of  33  additional  cases  under  observation 
for  a  shorter  period  than  four  weeks,  20  thrived  and  13  did  not. 

The  Dangers. — ^We  naturally  regard  the  dangers  of  having  tubercle 
bacilli  in  the  milk  as  one  of  the  prime  reasons  for  sterilizing  the  same.  \Ye 
should  never  employ  the  milk  from  one  cow,  but  always  from  a  mixed  herd. 

The  danger  of  transmitting  tuberculosis  is  certainly  very  rare.  Au- 
thentic cases  have  been  reported  from  time  to  time  in  medical  literature 


'Bacteriological   World.     December,    1891;    Journal    of   the   American   Medical 
Association,  February  27,  1892. 


132  NUTKITION. 

in  which  a  supposed  infection  could  be  attributed  to  milk.    E.  Koch  disputes 
the  possibility  of  transmitting  bovine  tuberculosis  to  man. 

In  a  herd  of  cows  which  has  undergone  the  proper  veterinary  inspection, 
the  danger  of  overseeing  tuberculosis  of  the  udder  is  reduced  to  a  minimum. 

Fat. 

While  it  is  true  that  a  new-born  infant  with  a  healthy  stomach  can 
tolerate  a  higher  fat  percentage  than  an  infant  with  a  weak  stomachy  great 
care  must  be  ezercised  to  avoid  overtaxing  the  digestive  functions,  so  that  a 
stomach  breakdown  does  not  result. 

Fat  Metabolism. — ^The  proper  amount  of  fat  that  an  infant  can  digest 
at  birth  is  between  1  and  2  per  cent.  After  several  weeks  2  per  cent,  will 
be  digested.  Nutritional  disturbances  such  as  regurgitation  and  vomiting 
of  sour-smelling  liquids  will  follow  the  feeding  of  more  fat  than  the  stom- 
ach can  tolerate.  Some  infants  will  thrive  on  2%  per  cent,  of  fat,  while 
others  demand  3  to  3%  per  cent,  of  fat  when  six  months  old.  The  stool 
of  excessive  fat-fed  infants  will  contain  round  or  lentil-shaped  particles  of 
fat.  Clinical  experience  has  demonstrated  that  vomiting,  colic,  and  restless- 
ness results  more  often  from  excess  of  fat  than  from  any  other  ingredient 
in  the  food. 

Eesearch  has  demonstrated  conclusively  that  fat  favors  nitrogen  excre- 
tion. The  higher  the  fat,  the  less  nitrogen  will  be  retained.  High  fats  usu- 
ally lead  to  the  development  of  soap  stools.  Of  the  total  fat  ingested  it  is 
estimated  that  87  to  98  per  cent,  will  be  absorbed. 

When  we  have  a  disturbance  of  fat  metabolism  there  results  a  relative 
acidosis.  Usuki  believes  that  the  soap  stool  is  caused  by  a  disturbance  of 
fat  metabolism  due  to  excessive  fat  absorption  rather  than  to  poor  fat  ab- 
sorption. Bahrdt's^  conclusions  are  just  the  reverse.  He  regards  the  soap 
stool  due  to  a  smaller  absorption  of  fatty  acids,  resulting  from  an  increased 
peristalsis  of  the  small  intestine,  which,  with  an  increased  excretion  of 
alkali,  results  in  the  formation  of  the  saponified  stool. 

The  urine  of  an  excessive  fat-fed  infant  contains  an  excess  of  ammonia. 
The-  condition  called  "acidosis"  results.  High  fat  feeding  results  in  an 
excess  of  volatile  acids  in  the  stomach  and  intestines.  If  the  text-books  of 
ten  and  twenty  years  ago  are  consulted  the  reader  will  find  that  the  high 
fats  were  generally  advocated.  Whole  milk  and  cream  or  top  milk  were 
strongly  recommended  for  general  feeding  methods.  That  this  was  a  fal- 
lacy has  now  been  demonstrated.  Finkelstein  believes  that  when  the  fat 
content  of  the  food  is  high,  the  disturbance  caused  thereby  lessens  the 
tolerance  for  sugar.  Fat  disturbances  can  be  made  out  independent  of 
whether  the  sugar  content  is  high  or  low. 


^Bahrdt,  Jahrb.  f.  Kinderh.,  1910,  249. 


FAT.  133 

Digestion  of  Fat. — The  digestion  of  fat  begins  in  the  stomach  and  is 
continued  in  the  intestine.  This  synthesis  of  the  fatty  acids  in  the  fat  is  a 
function  of  the  intestinal  epithelium  associated  with  the  secretion  of  the 
pancreas  and  other  intestinal  glands.  Regarding  the  absorption  of  fat,  we 
must  not  suppose  that  all  fat  found  in  the  faeces  is  unabsorbed  fat  from  the 
food.  Normally  the  stool  contains  from  1  to  10  per  cent,  of  fat,  besides  free 
fatty  acids  and  their  combinations  with  saponified  fats.  Fat  is  not  the  most 
important  item  of  nutrition,  because  fat  may  be  replaced  by  a  certain 
quantity  of  carbohydrate.  Whether  an  infant  could  live  entirely  without 
fat  and  receive  in  its  stead  a  given  quantity  of  carbohydrate  has  never  been 
proven.    Theoretically  it  is  possible. 

-  Bab  cock's  Milh  Test. — In  this  country  the  so-called  Babcock  milk  test, 
invented  by  Dr.  'S.  M.  Babcock,  has  been  adopted  in  preference  to  other 
practical  milk  tests,  in  creameries  and  cheese  factories  as  well  as  in  milk 


Fig.  43. — Centrifugal  Testing  Machine,  for  Handpower. 

laboratories.  The  cause  of  the  general  adoption  of  this  test  is  doubtless 
to  be  found  in  its  simplicity,  cheapness,  and  ease  of  manipulation.  Briefly 
stated,  the  test  is  operated  as  follows:  17.6  cubic  centimeters  of  milk  are 
measured  into  a  special  milk-test  bottle,  an  equal  quantity  of  commercial 
H2SO4  (specific  gravity,  about  1.83)  is  added,  and  after  mixing  the  two 
liquids  the  test  bottle  is  placed  in  a  centrifugal  machine  and  whirled  for 
four  minutes;  hot  water  is  then  added  to  the  bottle  to  bring  the  fat  into 
the  graduated  narrow  neck  of  the  bottle,  and  after  a  second  whirling  of  one 
minute  the  per  cent,  of  fat  in  the  milk  is  read  off  from  the  scale  of  the 
test  bottle. 

A  determination  of  fat  in  milk  by  this  method  takes  less  than  fifteen 
minutes,  and  when  care  is  taken  in  sampling  the  milk  the  reading  of  the 
result  is  accurate  to  within  one-tenth  of  1  per  cent.  Babcock  testei*s  are 
now  placed  on  the  market  by  many  manufacturers  of  dairy  supplies  and  at 
a  remarkably  low  price,  thanks  to  shai'p  competition  among  the  manufac- 
turers. The  testers  are  either  hand  or  power  (steam  or  motor)  machines 
and  built  to  hold  from  two  to  thirty  or  more  test  bottles  at  a  time.  The 
number  of  revolutions  at  which  they  must  be  run  ranges  from  800  to  1200 
per  minute,  according  to  the  diameter  of  the  testers. 


134 


NUTRITION. 


The  Determination  of  Fat. — The  simplest  method  is  by  the  cream  gauge 
(Fig.  44).  Although  its  results  are  only  approximate,  they  are  in  most 
cases  sufficiently  accurate  for  clinical  purposes.  The  tube  is  filled  to  the 
zero  mark  with  freshly  drawn  milk,  which  stands  at  a  room  temperature  for 
twenty-four  hours,  when  the  percentage  of  cream  is  read  off.  The  ratio  of 
cream  to  fat  is  approximately  5  to  3 ;  thus,  5  per  cent,  cream  represents  3 
per  cent,  fat,  etc. 

Another  rapid  method  is  by  Marchand's  tube. 

Marchand's  Test. — First  put  into  the  tube  five  cubic  centimeters  of 
milk,  up  to  the  line  M;  then  four  or  five  drops  of  liquor  sodge;  shake;  add 


n 


CO 


CMj 


t  m 


Fig.  44.— Graduated  Oream 
Gauge.  10  <iy2. 


Fig.  45.— Marchand's  Tube. 


Fig.  46.— Feser's  Lactoscope 


five  cubic  centimeters  of  ether,  up  to  the  line  E.     Cork,  and  shake  fifteen 

or  twenty  times;  add  90  per  cent,  alcohol,  up  to  the  line  A.     The  tube  is 

now  tightly  corked,  shaken  thoroughly,  and  placed  upright  in  a  tall  bottle 

containing  water  at  a  temperature  of  130°  to  150°  F.     The  fat  separates 

and  forms  a  distinct  layer  at  the  top,  and  after  half  an  hour  the  amount  is 

read  off  in  degrees.    By  reference  to  the  following  table  the  exact  percentage 

of  fat  is  shown: — 

Table  No.  20. 


Degrees,  Marchand. 

Perceutage  of  Fat. 

Degrees,  Marchand. 

Percentage  of  Fat. 

1 

1.49    - 

13 

4.29 

3 

1.96 

15 

4.75 

5 

2.42 

17 

5.22 

7 

2.89 

19 

5.68 

9 

3.36 

21 

6.14 

11 

3.82 

SUGAR.  135 

Each  additional  degree  on  the  tube  corresponds  to  0.23  per  cent,  of  fat. 
To  insure  accuracy  the  test  should  be  repeated  two  or  tliree  times  with  the 
same  specimen.^ 

Another  test  is  made  by  the  use  of  Fesei-'s  lactoscope.  (See  Fig.  46.) 
The  test  is  made  as  follows :  Four  cubic  centimeters  of  milk  are  measured 
off  in  a  pipet,  put  into  a  tube,  and  water  slowly  added,  shaking  from  time  to 
time  until  the  black  lines  of  the  porcelain  stem  at  A  are  clearly  visible 


Fig.  47. — Cows'  Milk,  Showing  Fat-globules,  Magnified  330  Diameters, 

through  the  mixture  of  milk  and  water.  The  percentage  of  fat  is  then  read 
off  on  the  glass  cylinder  at  the  level  of  the  water  added ;  thus,  if  the  water 
is  to  the  mark  4,  it  indicates  the  presence  of  4  per  cent,  of  fat.  This  test 
is  only  applicable  to  cows'  milk. 

Sugars  and  Carbohydrates. 

Each  sugar  has  its  specific  ferment  in  the  intestine.  Maltose  has  mal- 
tase,  lactose  has  lactase,  and  cane  sugar  has  invertin.  These  sugars  are  all 
acted  upon  in  the  mouth  by  the  ptyalin  of  the  saliva.  They  are  further 
acted  upon  by  the  diastatic  ferment  of  the  intestine  and  the  pancreatic 
juice,  which  transform  the  polysaccharide  into  monosaccharide. 


^  These  tubes  may  be  obtained  from  E.  Greiner,  51  William  Street,  New  York. 


136  NUTRITION. 

Before  the  starches  and  sugars  are  absorbed  by  the  walls  of  the  intes- 
tinal tract,  they  must  be  transformed  by  means  of  ferments  found  in  the 
saliva,  pancreatic  secretions  and  intestinal  juices. 

There  are  two  classes  of  ferments:  the  ^^amylolytic"  or  "diastatic," 
which  transforms  starches  into  sugars  and  dextrins,  and  those  known  as 
"invertin'^  ferments,  which,  found  in  the  mucous  membranes  of  small  intes- 
tijies  and  in  the  succus  entericus,  give  rise  to  glucose,  by  action  upon  the 
various  saccharoses. 

The  malted  foods  owe  their  nutritional  value  to  the  presence  of  dextrin 
and  maltose.  No  one  will  question  the  value  of  the  malted  foods  for  the 
relief  of  atonic  constipation.  The  carbohydrate  seems  to  limit  the  irritating 
properties  of  an  excessive  fat  mixture.  Likewise  the  carbohydrate  if  in  a 
proper  amount  seems  to  balance  the  improper  ratios  of  fat  and  protein 
in  artificial  feeding  mixtures.  As  a  rule,  5  per  cent,  of  the  food  mixture 
should  consist  of  the  carbohydrate  element.  This,  however,  need  not  be 
considered  the  point  of  tolerance  of  the  infant,  and  the  carbohydrate  may 
be  given  in  a  gradually  increased  percentage.  All  sugars  favor  water  re- 
tention; hence  the  weight  of  an  infant  will  increase  with  an  increased  per- 
centage of  sugar. 

Malt  Sugar. — -According  to  Finkelstein,  infants  will  tolerate  a  much 
higher  mixture  of  maltose  and  dextrin  than  either  lactose  or  cane  sugar. 
The  terms  ^^maltose'^  and  "malt  sugar,"  as  applied  to  the  carbohydrate  used 
in  infant  feeding,  are  inaccurate  and  misleading.  Pure  maltose  is  a  rare 
product  of  the  laboratory  and  is  never  employed  in  infant  feeding.  What 
is  really  meant  is  maltose  and  dextrin.  It  is  of  great  importance  that  this 
maltose  and  dextrin  should  be  derived  properly  (not  by  the  acid  process, 
but  in  a  natural  way),  by  the  action  of  the  enzymes  of  sound  barley  malt 
upon  prime,  full  wheat. 

In  many  cases  of  eczema  all  the  sugars,  even  maltose,  should  be  re- 
duced or  perhaps  eliminated  until  improvement  is  noted.  Convenient  prep- 
arations on  the  market  are  Mead's  dextri-maltose,  to  be  added  in  doses  of 
%  to  1  or  more  teaspoonfuls  to  each  feeding  bottle;  or  Loefflund's  malt  and 
Loefflund's  maltose  may  be  given  in  the  same  dosage. 

Milk  Sugar  (Lactose). — Milk  sugar  causes  abnormal  acid  fermentation; 
this  results  in  symptoms  of  intestinal  irritation  due  to  destruction  of  epi- 
thelium which  interferes  with  the  proper  emulsification  of  fats;  therefore, 
the  presence  of  fats  acts  as  an  additional  irritant  and  provokes  loose  bowels. 

When  intestinal  irritation  exists,  caused  by  the  presence  of  milk  sugar, 
the  symptoms  will  continue  even  though  the  milk  sugar  has  been  greatly 
reduced,  because  even  small  quantities  of  this  milk  sugar  will  keep  up 
lactic  acid  fermentation  and  consequent  destruction  of  the  epithelium. 

A  theoretical  reason  for  the  increase  in  bodily  weight  when  feeding 
sugar,  is  that  such  sugar  requires  a  certain  amount  of  water  to  hold  it  in 


PROTEIN.  137 

suspension.  Large  quantities  of  sugar  have  a  decided  influence  on  the  tem- 
perature of  the  body.  A  rise  in  temperature  will  follow  when  a  large  dose 
of  glucose  is  given,  and  a  higher  fever  cui-ve  will  be  noted  when  a  dose 
of  15  to  30  grams  of  lactose  has  been  given.  For  older  children  I/2  to  1 
tcaspoonful  of  milk  sugar  given  three  times  a  day  will  relieve  constipation. 

Cane  Sugar  (Sucrose).— Cane  sugar  is  less  irritating  to  the  intestinal 
mucosa  than  milk  sugar.  It  is  easily  assimilated,  and  for  this  reason  has 
many  advocates.  For  many  years  it  has  been  advocated  by  Jacobi.  I  have 
seen  good  results  therefrom.  When  malt  sugar  cannot  be  procured,  my 
advice  is  to  use  cane  sugar.  It  does  not  possess  laxative  properties.  When 
cane  sugar  is  used  no  more  than  2  to  3  per  cent,  of  the  total  quantity  of  food 
should  be  ordered. 

Cane  sugar  is  employed  in  commerce  to  preserve  milk  foods,  which 
proves  that  this  form  of  sugar  possesses  antibactericidal  properties. 

Protein. 

Under  this  heading  we  include  casein  and  albuminoids.  Protein  is 
the  most  important  constituent  of  food.  To  sustain  life,  to  increase  growth, 
to  reproduce  cell  waste,  and  to  develop  the  organism,  especially  muscle, 
bone,  and  teeth,  we  need  protein.  In  combination  with  a  sufficient  quantity 
of  fat,  carbohydrate,  and  salts,  the  physiological  development  of  the  body 
takes  place.  The  nitrogenous  waste  of  the  cells  of  the  body  can  be  replaced 
by  no  other  element  but  protein.  It  can  readily  be  seen  that  a  deficiency 
in  the  development,  growth,  and  maintenance  of  the  infant's  body  depends 
largely  on  the  assimilation  of  protein.  According  to  Pavy,  the  nitrogenous 
compounds  are  mainly  "histogenetic"  or  tissue-forming  material.  By  the 
separation  of  urea  which  occurs  in  this  metamorphosis  in  the  animal  sys- 
tem a  hydrocarbonaceous  compound  is  left  which  may  be  appropriated  to 
heat  production. 

The  protein  element  in  milk  is  best  adapted  for  infants.  This  animal_ 
food  can  be  replaced  only  temporarily  by  vegetable  protein.  Temporary 
success  may  be  noted  in  many  varieties  of  feeding,  especially  when  large 
quantities  of  carbohydrates,  be  they  sugars  or  starches,  are  fed  to  the  infant. 
When  a  large  gain  in  weight  is  desired,  then  starches  and  sugars  are  indi- 
cated. .  Disaster  will  invariably  result  from  the  prolonged  feeding  of  ex- 
cessive quantities  of  carbohydrates  if  the  protein  is  deficient.  Not  so  many 
years  ago,  protein  was  regarded  as  the  element  in  food  causing  the  greatest 
disturbance.  Cheesy,  curded  stools  thought  to  be  casein  indigestion  were 
later  found  to  be  fat  particles,  and  the  curded  masses  were  proven  to  be 
saponified  fats. 

Further  research  has  demonstrated  that  colic,  eructations,  and  vomit- 
ing are  most  frequently  caused  by  an  excess  of  fat.    What  was  supposed  to 


138  NUTRITION". 

be  the  harmful  element  and  the  food  element  mostly  feared,  namely,  protein, 
is  now  proven  to  be  the  element  giving  us  the  least  concern. 

An  excess  of  protein  has  decided  therapeutic  virtues  and  its  indication 
in  the  treatment  of  catarrhal  colitis  in  infancy  has  been  established.  Not 
more  than  a  dozen  years  ago  our  literature  warned  against  giving  an  excess 
of  protein,  and  advised  giving  %  to  1  per  cent,  in  a  feeding  mixture. .  Re- 
search studies,  combined  with  careful  clinical  observations,  have  demon- 
strated the  fact  that  double  the  quantity  of  protein  can  easily  be 
assimilated. 

The  protein  molecule  is  peculiar  when  compared  with  the  carbohydrate 
molecule.  The  toxicity  of  some  varieties  of  the  protein  molecule  due  to  the 
action  of  the  intestinal  ferments  or  the  intestinal  bacteria  will  be  appre- 
ciated when  we  consider  the  end-results,  such  as  fever,  rash,  and  general 
prostration;  then  we  have  anaphylaxis. 

There  is  a  decided  difference  between  the  protein  of  cows'  milk  and 
woman's  milk.  Boggs^  states  that  if  a  solution  of  phosphotungstic  and 
hydrochloric  acid  are  added  to  milk  in  an  Esbach  tube,  after  twenty-four 
hours  the  protein  will  precipitate  and  the  amount  can  be  read  off. 

When  we  examine  the  protein  of  woman's  milk,  we  find  the  analysis 
shows : — 

Wommi's  Milk  Cows'  Milk 

Caseinogen  Small  Amount  Large  Amount 

Lactalbumin  Large  Amount  Small  Amount 

In  woman's  milk  Konig  finds  the  lactalbumin  is  about  two-thirds  and 
the  caseinogen  about  one-third  of  the  total  protein.  In  cows'  milk  the 
lactalbumin  is  only  one-sixth  to  five-sixths  caseinogen. 

As  an  infant  grows  older,  its  power  to  digest  casein  becomes  propor- 
tionately greater.  In  the  latter  months  of  infancy,  the  tenth,  eleventh, 
and  twelfth,  its  proteolytic  function  has  become  adapted  to  this  change  in  the 
ratio  of  the  caseinogen  and  lactalbumin,  so  that  the  higher  total  protein, 
■such  as  2.50,  3,  3.50,  and,  finally,  4  per  cent.,  with  the  relatively  high 
caseinogen  and  low  lactalbumin,  become  the  proper  nutritive  portion  for 
the  infant. 

Albuminoids  in  Cows'  Milk. 

That  there  are  differences  in  the  amounts  of  the  albuminoids  occurring 
in  human  milk  is  proven  by  the  fact  that,  while  Professor  Leeds  found  a 
variation  of  0.85  to  4.86,  Professor  Meiggs  asserts  that  there  was  but  1  per 
cent. 

Konig,  an  earlier  analyst,  makes  the  variation  from  0.85  to  4.86.  Some 
of  these  results  give  as  high  a  percentage  of  albuminoids  in  woman's  milk 
as  we  find  in  cows'  milk,  and  I  have  no  doubt  in  my  own  mind  that  the  time 


^Boggs:    Johns  Hopkins  Bulletin  No.  187,  Oct.,  1906. 


COWS'  MILK. 


139 


and  habit  of  extracting  the  milk  has  a  deal  to  do  with  the  amount  of  occur- 
ring albuminoids.  In  other  words,  when  milk  is  extracted  every  two  hours 
or  less,  it  cannot  contain  as  much  of  the  cell-material  as  milk  from  the  same 
source  extracted  at  intervals  of  twelve  hours.  This  latter  is  riper,  and  it  is 
the  non-conformity  of  the  tissue  which  causes  all  the  difference  in  the  dif- 
ferent occurring  albuminoids.  We  know  that  during  the  incubation  of  eggs 
casein  is  developed  from  egg-albumin.  This  illustrates  the  ripening  of  albu- 
min. Furthermore,  take  an  egg  .Just  laid  by  the  hen,  and  boil'  it,  and  you 
will  find  immature  albumin  in  it,  that  is,  after  boiling,  instead  of  being 
thick  and  finn,  like  an  older  egg,  much  of  it  is  milky.  If  boiled  a  few  hours 
later,  all  the  albumin  will  coagulate  perfectly,  because  it  has  had  time  to 
ripen.  There  is  no  doubt  that  the  albuminoids  in  milk  from  healthy  animals 
are  all  cell-transformations,  not  an  exudate,  as  are  undoubtedly  the  fats  and 
salts,  because  these  latter  we  can  influence  by  the  food  very  plainly,  but  in 
health  the  albuminoids  are  constant  without  regard  to  food,  while  during 
menstruation,  pregnancy,  and  other  conditions,  notably  febrile  disturbances, 
we  find  the  fats  and  salts  not  materially  affected,  but  the  albuminoids  de- 
creased, increased,  or  totally  changed,  as  in  the  case  of  colostrum.  The 
casein,  besides  being  riper  in  cows'  milTc,  by  reason  of  its  stronger  growth, 
is  intended  by  ISTature  to  coagulate  into  a  hard  mass,  because  it  is  the  product 
of  a  cud-chewer  for  the  nourishment  of  a  cud-chewer,  and  the  reason  why 
it  does  not  always  coagulate  in  the  infant's  stomach  as  it  does  in  that  of 
the  calf  is  that  the  latter  animal's  stomach  secretes  a  principle  called  clnj- 
mosin;  this  is  the  principle  that  curdles  cows'  milk,  and  it  operates  either 
in  an  acid  or  an  alkaline  medium.  Pepsin  will  not  coagulate  mill',  and 
hence  the  hard  coagulum  of  cows'  milk  that  sometimes  forms  in  the  infant's 
stomach  is  due  to  acidity  of  that  organ,  and  this  acidity  is  not  always  the 
fault  of  the  stomach,  but  of  the  milk  itself.  The  variations  in  the  chemistry 
of  the  albuminoids  found  in  cows'  milk  would  not  be  surprising  to  anyone 
if  he  would  examine  into  the  condition  of  some  of  its  mammary  sources. 
Thus  it  will  often  be  found,  on  dissecting  a  cow's  udder,  that  there  are  old 
cicatrices,  one  or  more  quarters  of  the  udder  intensely  inflamed,  sometimes 
a  mammiferous  duct  clogged  with  a  calculus  or  a  clot  of  fibrin.  Besides 
these  pathological  conditions,  the  mammary  gland  is  subject  to  benign  and 
malign  infiltrations,  bacillary  tubercular  deposits,  and  eruptive  diseases  of 
the  skin  involving  the  gland  and  ducts.  Therefore,  that  fibrin,  serum,  and 
albumin,  in  various  forms,  are  found  in  the  cow's  milk  is  not  surprising,  and 
it  can  safely  be  assumed  that  any  variation  in  the  albuminoids  from  the 
normal  casein  can  be  ascribed  to  sickness  on  the  part  of  the  animal. 

Curds  in  Cows'  Milk. — Milk  curdles  under  two  entirely  distinct 
sets  of  conditions:  (1)  it  curdles  on  addition  of  an  acid,  and  (2)  it  curdles 
under  the  infiuence  of  rennet  (when  the  reaction  of  the  milk  is  either  neutral 
or  slightly  acid) .    The  two  varieties  of  curds  which  may  be  obtained  under 


140  NUTRITION. 

these  circumstances  may  be  denominated  "acid  curds"  and  "rennet  curds/' 
respectively.  Acid  curds  must  inevitably  be  formed  in  the  stomach  after 
milk  has  been  drunk,  if  the  gastric  contents  are  allowed  to  become  acid. 
Such  curds  (we  are  familiar  with  them  in  ordinary  life  in  the  form,  for 
instance,  of  cream-cheese  or  sour-milk)  are  probably  not  sufficiently  firm  to 
set  up  digestive  disturbances.  On  the  other  hand,  rennet  curds  (such  as  we 
are  familiar  with  in  the  form  of  renneted  milk  and  of  ordinary  cheese)  may 
be  extremely  firm. 

Casein". 

Casein  can  be  fed  to  very  sick  infants  and  will  be  assimilated  in  small 
or  in  large  doses.  Casein  stimulates  alkaline  secretion;  hence,  acts 
antagonistic  to  pathological  acid  fermentation.  Casein  is,  therefore,  indi- 
cated to  combat  diarrhoea.  This  teaching,  based  on  experimental  feeding, 
reverses  our  former  theories  concerning  the  dangers  of  giving  large  per- 
centages of  protein.  This  form  of  food,  recommended  by  Finkelstein,  of 
Berlin,  has  gained  a  strong  foothold  in  many  clinics  abroad.  It  has  been 
successfully  used  by  me  in  cases  of  intestinal  disturbance,  enteritis  (dys- 
pepsia), atrophy  (decomposition),  and  cholera  infantum  (intoxication). 
Fever,  if  present,  does  not  contraindicate  the  use  of  this  food.  It  has  a 
low  sugar  and  a  low  salt  content. 

Casein  Milk  (Eiweiss  Milch;  Albumin  Milk). — The  milk  is  prepared 
as  follows^ :  Heat  1  quart  of  full  milk  to  100°  F.  Add  4  teaspoonfuls  of  the 
essence  of  pepsin  and  stir.  Let  this  mixture  stand  at  100°  F.  until  the 
curd  has  formed  (this  usually  takes  about  one-half  hour).  Filter  the 
whey  from  the  curd  by  means  of  a  linen  cloth,  and  discard  the  whey. 
The  curd  is  then  removed  from  the  cloth  and  pressed  through  a  rather  fine 
seive  two  or  three  times  by  means  of  a  wooden  mallet  or  spoon.  One  pint  of 
water  is  added  to  the  curd  during  this  process.  The  mixture  should  now 
look  like  milk,  and  the  precipitate  must  be  very  finely  divided.  To  this 
mixture  1  pint  of  buttermilk  is  a,dded. 

The  composition  of  this  "casein  milk"  is  as  follows: — ■ 

Protein 3.0  per  cent. 

Fats    2.5  per  cent. 

Sugar 1.5  per  cent. 

Salts 0.5  per  cent. 

Casein  milk  should  be  given  in  small  quantities  2  to  4  ounces  in 
enteritis,  and  in  large  amounts  6  to  8  ounces  in  atrophy,  every  three  or  four 
hours,  depending  on  the  age  of  the  infant.  Sugar  should  not  be  added  until 
the  stools  are  homogeneous.  Until  sugar  is  added  the  weight  does  not 
increase.    Malt  sugar  or  cane  sugar  should  be  used.    This  method  of  feeding 

^Archives  of  Pediatrics,  August,  1910. 


MINERAL   SALTS.  141 

should  be  continued  for  months,  but  should  always  be  used  as  a  corrective 
for  the  gastrointestinal  disturbance.  It  should  be  used  as  a  substitute  feed- 
ing if  artificial  feeding  disagrees  or  deranges  the  gastrointestinal  tract. 

Mineral  Salts.^ 

The  growth  of  the  body  requires  salts.  Such  salts  are  found  in  human 
milk  and  in  cows'  milk;  thus,  calcium,  phosphorus,  and  magnesium  neces- 
sary for  bone  building  form  a  large  part  of  the  ash.  Cows'  milk  contains 
more  than  twice  as  much  potassium,  five  times  as  much  sodium,  phosphorus, 
and  calcium,  four  times  as  much  magnesium  and  chlorine,  and  six  times  as 
much  sulphur. 

From  the  studies  of  Blauberg,  Soldner,  and  Hoobler,  we  note  that  the 
ash  intake  in  artificially  fed  infants  is  six  to  nine  times  greater  than  that  of 
breast-fed  infants. 

Calcium. — ^Of  the  ash  in  woman's  or  cows'  milk  one-fifth  consists  of 
calcium.  It  usually  enters  the  body  in  'organic  form.  The  organic  com- 
bination is  present  in  milk,  yolk  of  egg,  and  vegetables.  Calcium  is  the 
largest  mineral  constituent  of  the  body.  It  is  present  as  calcium  phosphate, 
which  makes  up  a  large  part  of  the  bone  salts.  Jacques,  Loeb,  and  Blau- 
berg have  shown  that  infants  who  cannot  metabolize  calcium  cannot  survive. 

The  calcium  intake  in  cows'  milk  feeding  is  about  eight  times  greater 
than  in  woman's  milk;  the  amount  actually  absorbed  and  retained  is 
four  times  greater  on  cows'  milk  than  on  woman's  milk.  However,  a  much 
larger  percentage  of  woman's  milk  calcium  is  retained.  It  is  evident,  there- 
fore, that  the  calcium  of  woman's  milk  is  much  better  metabolized  than  the 
calcium  of  cows'  milk,  and,  since  a  healthy  nursing  infant  shows  no  signs  of 
a  deficiency  of  calcium,  we  may  well  consider  the  amount  which  it  gets  as 
being  the  true  calcium  need.  The  absorption  of  calcium  depends  in  part 
on  the  presence  of  accompanying  salts;  for  example,  if  much  alkali  bases 
are  present  in  the  intake  the  absorption  is  diminished,  whereas  NaCl  assists 
in  calcium  absorption.  Calcium  is  more  readily  absorbed  on  flesh  than  on 
a  vegetable  diet. 

Woman's  milk  and  cows'  milk  contain  very  small  quantities  of  iron. 
Were  it  not  for  the  large  amount  stored  in  the  liver  and  blood  of  the  new- 
born there  would  be  a  deficiency  in  the  early  months  of  feeding. 

The  organic  forms  occur  in  the  nucleoalbumins,  in  milk,  yolk  of  egg, 
and  in  many  vegetables. 

Phosphorus. — Organic  phosphoinis  occurs  in  milk,  eggs,  and  legumes. 
As  an  organic  combination  it  is  found  as  nucleoalbumin,  nuclein,  vitellin. 
casein,  and  lecithin.     The  nucleins  make  up  41.5  per  cent,  of  the  total 


^I  am  indebted  to  Raymond  Hoobler  for  many  points  in  the  preparation  of 
this  article. 


142  NUTRITION. 

phosphorus  of  woman's  milk,  while  in  cows'  milk  only  6  per  cent,  is  in  that 
form.  In  woman's  milk  35  per  cent,  of  total  phosphorus  is  in  the  form  of 
lecithin,  while  the  lecithin  of  cows'  milk  is  but  5  per  cent.,  according  to 
Stocklasa. 

Sodium  and  Potassium. — It  should  be  remembered  that  both  alkaline 
and  acid  solutions  exist  within  the  same  body;  that  the  blood,  various 
secretions,  as  well  as  each  body  cell,  have  a  definite  amount  of  alkali,  and 
can  vary  only  within  very  narrow  limits,  in  order  that  they  may  perform 
their  proper  functions.  This  automatic  regulation  of  alkalinity  of  the  tissues 
and  fluids  is  one  of  the  marvels  of  the  human  mechanism,  and  it  is  remark- 
able how  rarely  it  varies  sufficiently  to  produce  a  pathogenic  condition.  It  is 
for  the  maintenance  of  this  stupendously  important  work  that  the  fixed 
alkalies,  sodium  and  potassium,  are  used.  Albu  and  Neuberg^  have  ex- 
plained this  self-regulation  thus :  Through  the  tearing  down  of  the  albumin 
of  the  body  and  the  albumin  taken  in  in  the  food,  sulphuric  and  phosphoric 
acids  are  set  free  and  must  be  neutralized  by  the  alkalies  of  the  blood. 
These  acids  would  draw  out  the  fixed  alkalies  were  it  not  for  the  supply  of 
carbonate  derived  from  the  carbonic  acid  and  from  the  vegetable  salts  taken 
in  the  food.  At  certain  times  when  the  breaking  down  of  albumin  is  ex- 
cessive, ammonia  is  also  set  free  and  this  is  used  along  with  the  carbonates 
for  the  fixing  of  the  acids.  By  means  of  this  sort  of  neutralization,  the 
acids  become  a  constituent  of  the  body,  the  fixed  alkalies  remain  untouched, 
and  the  alkalinity  of  the  tissues  is  unchanged.  Should  this  reaction  suffer 
the  least  change,  either  through  a  lessening  of  the  bases  or  an  increase  of 
the  autogenous  acids,  the  organism  becomes  at  once  in  danger. 

Sodium  Chloride. — Of  all  mineral  constituents,  sodium  chloride  has  the 
most  important  function  to  perform.  Not  only  does  it  rqtain  but  it  ex- 
cretes water.  Because  of  the  well-known  fact  that  salt  requires  water  for  its 
retention,  the  salt-free  diet  was  suggested  to  relieve  oedema  and  thereby 
favor  excretion  of  water.  Sulphur  is  found  in  woman's  as  well  as  cows' 
milk,  but  its  importance  has  not  yet  been  fully  determined. 

Hoobler  concludes  as  follows :  Salts  are  necessary  to  maintain  life. 
They  are  best  absorbed  and  utilized  when  in  organic  combination  with  food- 
stuffs. There  are  marked  differences  in  the  salt  content  of  woman's  and 
cows'  milk  which  should  be  considered  in  artificial  feeding.  Certain 
pathological  conditions  arise  in  which  certain  of  the  salts  are  not  absorbed, 
even  though  in  abundance  in  the  food.  In  certain  other  pathogenic  condi- 
tions salts  are  actually  withdrawn  from  the  body  to  such  an  extent  as  to  im- 
poverish the  organism  and  produce  grave  disturbances  of  nutrition.  The 
various  salts,  with  the  exception  of  iron,  are  present  in  sufficient  quantities 
and  proper  proportions  in  woman's  milk.    In  most  of  the  dilutions  of  cows' 


•  Mineralstoifwechsel,  Berlin,  1906,  p.  70. 


MINERAL  SALTS.  I43 

milk  there  is  an  excess  of  salts,  which  may  be  neglected  in  feeding  normal 
infants,  but  which  plays  an  important  role  in  the  feeding  of  children  already 
suffering  from  nutritional  disturbances.  The  conditions  under  which  the 
salt  content  of  feedings  should  be  altered,  and  in  just  what  degree  each  or 
all  should  be  varied,  are  still  unsolved  problems. 

The  Addition  of  Lime-water,  Bicarbonate  of  Sodium,  or 
Other  Alkalies  to  Cows'  Milk. 

Lime-water  is  the  alkali  usually  selected  for  neutralizing  the  acidity 
in  cows'  milk.  It  acts  by  partly  neutralizing  the  acid  of  the  gastric  juice, 
so  that  the  casein  is  coagulated  gradually  and  passes,  in  great  part,  un- 
changed into  the  intestine,  to  be  there  digested  by  the  alkaline  secretions. 
As  it  contains  only  i/o  grain  of  lime  to  the  fiuidounce,  the  desired  result 
cannot  be  attained  unless  at  least  a  third  part  of  the  milk-mixture  be  lime- 
water.  Instead  of  lime-water,  3  to  4  grains  of  bicarbonate  of  sodium  may 
be  added  to  each  bottle,  or,  better  still,  from  5  to  15  drops  of  the  saccharated 
solution  of  lime. 

This  solution  is  made  in  the  following  way : —  ' 

IJ   Slaked  lime    1  ounce 

Refined  sugar,  in  powder   2  ounces 

Distilled  water    1  pint 

Mix  the  lime  and  sugar  by  trituration  in  a  mortar.  Transfer  the 
mixture  to  a  bottle  containing  the  water,  and,  having  closed  this  with  a  cork, 
shake  it  occasionally  for  a  few  hours.  Finally,  separate  the  clear  solution 
with  a  siphon  and  keep  it  in  a  stoppered  bottle. 

Bicarbonate  of  Soda  Solution  {Baking  Soda). — ^Take  1  grain  of  soda 
bicarbonate  to  I/2  ounce  of  water.  Or  1  drachm  of  soda  bicarbonate  to  1 
quart  of  water.    This  is  the  proper  strength  used  for  diluting  milk. 

Quantity  to  he  Used. — One  tablespoonful  of  the  last-named  solution 
equals  in  strength  1  tablespoonful  of  ordinary  lime-water. 

Both  lime-water  and  soda-bicarbonate  solution  should  be  kept  in  very 
clean,  well-stoppered  bottles  and  in  a  cool  place. 

The  teaching  that  lime-water  should  be  added  to  render  cows'  milk 
alkaline,  and  thereby  resemble  human  milk,  has  been  studied  by  Kerley, 
Gieschen,  and  Meyers,  whose  conclusions  are  very  interesting.  They  say 
that : — 

1.  Breast-milk  and  cows'  milk  are  both  acid. 

2.  The  litmus-paper  test  for  milk  is  unreliable  because  of  the  varia- 
tion in  the  quality  of  litmus  paper,  and  the  litmus  taking  part  in  the 
reaction  and  not  acting  as  an  indicator. 

3.  The  effect  of  adding  lime-water  or  bicarbonate  of  sodium  to  feeding 
is  to  retard  or  inhibit  the  formation  of  curds  by  rennet. 


144  NUTRITION. 

4.  The  teaching  that  lime-water,  bicarbonate  of  sodium,  or  carbonate 
of  potassium  should  be  added  to  fresh  milk  or  feedings  simply  because  they 
are  antacids  is  erroneous. 

6.  The  addition  to  milk  or  feedings  of  alkalies  or  salts  that  become 
alkaline  in  solution  is  an  empirical  method  of  aiding  digestion  by  prevent- 
ing the  formation  of  dense  curds  that  would  slowly  leave  the  stomach  and 
be  difficult  of  digestion  in  the  intestine. 

In  one  respect  I  do  not'  agree  with  them,  and  that  is  in  regard  to  the 
addition  of  bicarbonate  of  potassium.  In  weak  infants,  especially  in  maras- 
mic  cases  and  in  those  infants  in  which  "milk  colic"  appears  one  or  two 
hours  after  being  fed  with  cows'  milk,  I  have  found  that  by  the  addition 
of  10  to'  15  grains  of  bicarbonate  of  potassium  to  each  feeding  improve- 
ment was  invariably  noted.  I  have  not  found  this  improvement  when 
bicarbonate  of  soda  or  lime-water  was  added. 

VlTAMINES.^ 

Vitamines  are  found  in  the  external  shell  or  kernel  of  the  cereals. 
They  can  be  extracted  in  the  form  of  colorless,  needle-shaped  crystals.  They 
are  necessary  as  a  live  factor  in  nutrition.  If  we  give  a  cereal  minus  the 
hull  or  shell  we  deprive  the  child  of  one  of  the  most  important  elements  of 
its  nutrition- — namely,  its  vitamine. 

It  has  been  experimentally  proven  that  scurvy,  rickets,  and  beriberi 
can  be  developed  by  giving  food  lacking  in  vitamine.  On  the  other  hand, 
the  disease  can  be  arrested  and  cured  by  adding  the  vitamines  to  the  food. 

The  absence  of  vitamines  in  the  food  is  responsible  for  the  development 
of  specific  diseases,  which  have  been  called  deficiency  diseases  or  avitaminosis. 
Eickets,  scurvy,  or  Barlow's  disease,  pellagra,  and  beriberi  are  some  of  the 
diseases  belonging  to  this  group. 

When  pigeons  are  fed  on  rice  from  AA^^hich  the  vitamines  have  been 
removed  they  linger  and  die.  It  has  been  found  that  by  feeding  adults  or 
children  rice  from  which  this  substance  has  been  removed  beriberi  will  result. 
Funk  found  that  when  this  specific  vitamine  was  given  to  such  patients, 
although  fed  on  polished  rice,  they  recovered. 

Eickets  was  formerly  believed  due  to  a  lack  of  sufficient  protein  and 
fat  in  the  diet.  It  is  now  recognized  that  rickets  is  most  likely  due  to  the 
absence  of  vitamines,  which  are  necessary  for  the  proper  metabolism  of  fat 
and  protein.  That  the  vitamines  >stimulate  the  thymus  and  the  parathyroids 
seems  plausible,  and  when  they  are  absent  from  the  food  there  results  either 
rickets  or  tetany. 

Vitamines  are  found  in  the  Ijrain  of  the  ox,  also  in  lecithin  and  in 
testiculin  as  sold  in  commerce.  Cereals  such  as  oats,  wheat,  barley,  and 
various  kinds  of  beans  contain  vitamine,  so  also  fresh  vegetables. 


^Die  Vitamine,  by  Casimir  Funk,  Wiesbaden,  1914. 


PLATE  V 


Microscopic  Appearance  of  Raw  Starch-granules. 


PLATK   Xl 


Microscopic  Appearance   ot   Starcli   iiianules,  showing  the  effect  of   Heat. 


STARCH.  145 

Vitamines  are  best  administered  in  the  form  of  yeast  with  yolk  of  egg. 
Funk  lias  found  that  beriberi  is  not  due  to  an  infection  or  intoxication,  but 
is  caused  by  a  deficiency  of  this  vitamine. 

The  absence  of  vitamine  is  noticeable  in  polished  rice,  white  bread  and 
starch.  If  to  this  food  we  add  yeast  or  beans,  then  we  add  vitamines  which 
are  required  for  tlie  development  of  the  organism. 

Vitamines  in  milk  are  sometimes  dependent  on  the  nutrition  of  the 
cows;  thus  we  find  that  milk  of  cows  lacking  fresh  fodder,  as  for  example  in 
winter,  will  produce  less  vitamines.  It  is,  therefore,  quite  plausible  that  the 
use  of  such  milk  may  be  a  factor  in  the  causation  of  rickets.  Funk  states 
that  the  vitamines  are  practically  destroyed  by  moderate  heating  of  milk,  and 
are  completely  destroyed  by  the  sterilization  of  milk.  We  can,  however,  add 
vitamines  to  sterilized  milk  and  tlius  render  it  nutritious  and  also  anti- 
scorbutic. 

Antiscorbutic  Diet. — Fresh  green  vegetables  like  lettuce,  cauliflower, 
onions,  potatoes,  apples,  oranges,  lemons,  raw  milk,  yolk  of  egg,  meat, 
wheat,  oats,  and  barley. 

Juicy  fruits  and  vegetables  lose  their  vitamines  (scurvy  vitamine)  en- 
tirely on  drying  or  heating  to  212°  F.  for  one  hour.  The  action  of  the 
vitamines  resembles  that  of  hormones  and  the  secretions  of  the  ductless 
glands.  Albuminous  substances  vary  in  their  nutritive  value  depending  on 
the  presence  or  absence  of  amino-acids.  In  like  manner  there  are  certain 
foods  the  value  of  which  is  dependent  on  their  vitamine  content.  Chemical 
examination  shows  that  vitamines  occur  in  maize  in  very  similar  fashion  to 
rice  in  the  peripheral  layers. 

Enzymes  (Effront  and  Prescott). 

The  enzymes,  soluble  ferments,  zymases,  or  diastases,  are  active  organic 
substances  secreted  by  cells,  and  have  the  property,  under  certain  conditions, 
of  facilitating  chemical  reactions  between  certain  bodies,  without  entering 
into  the  composition  of  the  definite  products  which  result.  These  substances 
play  a  very  important  part  in  the  phenomena  of  assimilation  and  of  dissimi- 
lation of  foods.  In  fact,  most  of  the  foods  which  occur  in  Nature  at  the 
disposition  of  men,  lower  animals,  or  plants  are  not  directly  assimilable; 
they  require  the  intervention  of  a  diastase  in  order  to  be  transformed  into 
substances  assimilable  and  suitable  for  the  formation  of  new  tissues. 

Starch. 

Amylaceous  dilutions  of  milk  have  been  in  use  very  many  years.  They 
increase  the  carbohydrate ;  besides  aid  mechanically  in  breaking  up  the  curd 
into  fine  particles,  thus  rendering  it  more  digestible.  The  saliva  of  the 
newly  born  infant  can  dextrinize  starch.    Starch  is  not  assimilated  as  such, 

10 


146  NUTRITION. 

but  is  transformed  into  maltose  and  glucose.    These  latter  are  suitable  for 
the  construction  of  tissues. 

Cereals. — In  the  feeding  of  infants  we  should  give  sugar  to  supply  the 
carbohydrate  element  in  preference  to  starchy  foods.  Cereals  should  not  be 
ordered  until  the  infant  is  six  months  old  or  until  the  teeth  begin  to  appear. 
Experience  has  shown  fair  quantities  of  starch  can  be  digested  as  early  as  the 
third  month.  My  method  has  been  to  use  cereal  dilutions  such  as  barley 
water  or  rice  water  to  dilute  cows'  milk  after  the  third  month.  When  the 
infant  is  6  months  old  it  is  safe  to  feed  a  small  saucer  of  well-steamed 
cereal,  but  care  must  be  used  to  avoid  starch  indigestion,  which  condition  is 
brought  about  by  improper  cooking  of  cereals  and  by  overfeeding  or  feeding 
excessive  quantities  of  carbohydraies. 

Ckeam, 

When  food  contains  too  little  fat,  or  its  equivalent  (cream),  we  have 
fat-starvation,  which  is  soon  manifested  by  symptoms  of  rickets.  One  of 
the  earliest  symptoms  of  rickets  is  constipation,  showing  deficient  muscular 
tone :  a  distinct  atony  of  the  bowel. 

This  can  be  remedied  by  the  addition  of  fat  or  cream  to  the  food. 
Some  children  are  benefited  by  giving  them  codliver-oil,  butter,  or  olive-oil ; 
thus,  it  is  plain  that  each  one  desires  to  remedy  the  deficiency  of  fat  in  his 
own  manner. 

In  buying  cream  from  small  milk-stores  one  can  make  a  rough  guess 
at  the  proportion  of  fat  in  cream  by  its  thickness.  A  50-per-cent.  cream  at 
the  ordinary  temperature  of  the  room  runs  from  a  jug  slowly  and  in  a 
thick  stream,  almost  like  thick  mucilage,  whereas  a  16  per  cent,  cream 
runs  alm.ost  as  freely  as  milk.  This  is,  however,  a  crude  way  of  estimating 
the  difference  between  poor  and  rich  cream.  It  is  a  very  important  point 
to  know  exactly  what  percentage  of  cream  we  are  using,  for  such  mixtures 
like  Biedert's,  in  which  1  ounce  of  cream  is  mixed  with  3  ounces  of  water, 
may  agree  very  well  when  we  use  a  16  or  20  per  cent,  cream,  but  might  be 
disastrous  if  we  use  a  cream  containing  40  per  cent,  of  fat.  Such  infants 
would  not  tolerate  this  rich  cream,  and  might  have  troublesome  vomiting. 

Cream  for  Home  Modification. — Ordinary  Cream.-  This  is  made  by 
setting  milk  at  night  and  skimming  it  in  the  morning;  it  is  called  gravity, 
or  skimmed,  cream,  and  contains  16  per  cent,  of  fat. 

Twelve  Per  Cent.  Cream. — Obtained  in  the  city  by  using  equal  parts 
of  ordinary  (20  per  cent.)  centrifugal  cream  and  plain  milk.  In  the 
country  we  must  use  2  parts  of  ordinary  skimmed,  or  gravity,  cream  (16 
per  cent.)  with  1  part  of  plain  milk,  or  by  taking  the  top  layer  of  milk, 
after  it  has  stood  five  or  six  hours,  by  means  of  siphoning. 

Eight  per  cent,  cream  is  obtained  in  the  city  by  diluting  1  part  of  cen- 
trifugal (20  per  cent.)  cream  with  3  parts  of  plain  milk;  in  the  country. 


CREAM. 


147 


by  using  1  part  of  gravity  cream  and  2  parts  of  plain  milk,  or  by  using  the 
top  layer  of  milk  that  has  been  standing  five  or  six  hours,  siphoning  it  off. 

How  to  Procure  Cream. — Set  aside  the  ordinary  quart  bottle  of  milk 
on  the  ice  for  several  hours  (from  six  to  eight  hours)  to  allow  the  cream  to 
rise.  After  the  cream  has  risen  draw  the  milk  from  the  bottom  of  the 
bottle ;  this  can  be  accomplished  by  means  of  a  siphon. 

To  make  the  siphon,  get  a  piece  of  glass  tubing  21  inches  in  length  and 
a  quarter  of  an  inch  in  caliber.  This  can  be  procured  in  any  drug  store. 
German  glass  is  less  liable  to  crack  than  American  glass.  If  the  glass  tubing 
is  longer  than  21  inches  make  a  small  scratch  in  it,  after  measuring  off  21 
inches,  with  a  three-cornered  file,  then  grasp  the  glass  tubing  between  the 
fingers  and  opposing  thumbs  of  both  hands,  having  the  thumb-nails  touch- 


■^ 


Fig.  48. — Chapin  Cream  Dipper. 


ing  each  other  on  the  side  of  the  glass  just  opposite  to  the  scratch.  On 
attempting  to  bend  the  glass  tube  it  will  break  smoothly  across,  and  if 
there  are  any  sharp  edges  they  can  be  smoothed  by  rubbing  down  with  the 
file. 

To  bend  the  glass  tube  to  the  V  shape,  hold  it  in  the  flame  of  an  ordi- 
nary gas  jet  or  alcohol  lamp  for  a  few  moments,  twirling  the  glass  rod  until 
it  softens  sufficiently  to  allow  it  to  be  bent  to  the  required  angle.  The  tube 
should  be  warmed  gradually  at  first,  and  then  put  right  into  the  flame.  It 
is  better  in  bending  the  glass  to  make  one  arm  of  the  siphon  a  few  inches 
longer  than  the  other. 

In  using  the  siphon  hold  it  with  the  angle  down,  fill  it  with  water, 
and  close  the  long  arm  with  the  tip  of  the  finger;  then,  keeping  the  finger 
applied  to  the  long  end,  turn  the  siphon  with  the  angle  up,  and  introduce 
the  short  arm  into  the  bottle  of  milk,  letting  it  rest  upon  the  bottom.  On 
removing  the  finger,  the  milk  will  flow  through  the  tube,  and  continue  to 


148  NUTRITION. 

do  so  until  the  bottle  is  empty.  It  is,  therefore,  necessary  to  watch  the 
layer  of  cream,  so  that  the  siphon  can  be  lifted  out  of  the  bottle  just  before 
the  cream  reaches  it.  There  will  thus  remain  in  the  milk-bottle  all  of  the 
cream  and  a  small  portion  of  the  milk,  the  latter  depending  upon  the  ex- 
pertness  of  the  person  using  the  siphon. 

A  simpler  method  of  obtaining  the  cream  is  by  the  use  of  a  cream 
dipper  (see  Fig.  48).  This  can  be  purchased  at  any  large  drug-store.  The 
illustration  explains  itself. 

To  Pasteurize  the  Cream. — Take  a  clear  glass  bottle  having  a  neck  not 
very  wide;  fit  into  the  same  a  perforated  cork  with  a  chemical  thermom- 
eter registering  up  to  213°  F.  The  bulb  of  the  thermometer  should  come 
within  half  an  inch  of  the  bottom  of  the  bottle.  The  cream  is  put  into  the 
bottle,  and  the  cork  carrying  the  thermometer  is  inserted;  the  bottle  is 
then  placed  in  a  pot  containing  a  couple  of  inches  of  warm  water  and 
allowed  to  heat  on  the  stove.  The  thermometer  should  be  watched  until 
it  reaches  140°,  taking  care  that  it  does  not  go  above  140°.  When  the  ther- 
mometer has  reached  this  point,  set  the  pot  back  on  the  stove,  where  it  will 
cool  off,  and  allow  it  to  remain  there  for  twenty  minutes.  At  the  end  of 
this  time  substitute  a  plug  of  absorbent  cotton  for  the  cork  containing  the 
thermometer.  Great  care  must  be  taken  to  keep  the  absorbent  cotton  dry. 
Cream  thus  prepared  is  pasteurized,  and  will  keep  sweet  and  fresh  for 
twenty-four  hours  without  being  kept  on  ice,  and  all  that  is  necessary  in 
removing  a  portion  from  the  bottle  is  to  be  sure  that  the  cotton  plug  does 
not  become  moist,  or,  if  it  should,  to  replace  it  with  a  dry  piece  at  once. 

To  Clean  the  Glass  Siphon. — It  is  advised  to  fill  it  with  water  imme- 
diately after  using  it,  and  the  ordinary  tube-brush  having  eighteen 
inches  of  wire  added  to  it  will  permit  thorough  cleansing.  IvTothing,  how- 
ever, will  be  found  as  good  as  thorough  boiling  in  plain  water  to  which  a 
pinch  of  soda  has  been  added. 

Modification  of  Milk. — It  has  been  shown  previously  that  the  percent- 
ages of  fat  in  woman's  and  in  cows'  milk  are  about  the  same,  that  the 
quantity  of  sugar  is  rather  lower  in  cows'  milk,  and  that  the  quantity  of 
casein  and  albumin  is  greater  in  cows'  milk,  as  is  also  the  ash.  Experience 
has  shown  that  cows'  milk  must  be  diluted  before  it  can  safely  be  fed  to 
infants.  Simply  diluting  the  milk  reduces  the  percentages  of  fat  and  sugar 
too  much ;  so  that  the  practice  of  adding  cream  and  sugar  has  arisen,  but  the 
processes  that  have  been  advocated  for  obtaining  the  desired  additional 
quantities  of  fat  and  sugar  have  been  too  complicated  for  general  use. 

The  top  9  ounces  of  a  quart  of  milk  on  which  the  cream  has  risen  will 
be  about  three  times  as  rich  in  fat  as  the  whole  milk,  the  top  15  or  16 
ounces  will  be  about  twice  as  rich  as  the  whole  milk,  while  the  other 
ingredients  remain  about  the  same  as  in  whole  milk. 

For  babies  under  three  months  of  age  the  top  9  ounces  of  a  quart  of 


CREAM.  149 

milk  on  which  the  cream  has  risen  should  be  diluted  from  three  to  ten 
times  and  1  part  of  sugar  added  to  25  parts  of  food. 

For  babies  under  three  months  of  age  the  top  9  ounces  of  a  quart  of 
milk  on  which  the  cream  has  risen  should  be  diluted  two  or  three  times 
and  1  part  of  sugar  added  to  25  or  30  parts  of  food. 

For  babies  six  to  nine  months  old  the  top  20  ounces  of  a  quart  of 
milk  on  which  the  cream  has  risen  should  be  diluted  one-half  to  one  time 
and  1  part  of  sugar  added  to  50  parts  of  food.  An  even  tablespoonful  of 
granulated  sugar  equals  half  an  ounce. 

By  following  this  method  the  infant  commences  on  weak  mixtures 
that  show  about  the  same  composition  and  variations  as  woman's  milk 
and  gradually  takes  food  richer  in  casein  until  plain  milk  is  reached. 

The  diluents  used  are  water,  gruels,  or  dextrinized  gruels,  which  are 
simply  ordinary  gruels  the  starch  of  which  has  been  converted  into  soluble 
forms,  leaving  the  cellulose  and  proteins  of  the  cereal  in  a  finely  divided 
state.    The  effect  of  the  different  diluents  will  be  mentioned  farther  on. 

The  indiscriminate  feeding  of  cream,  to  strengthen  the  bab)^,  cannot 
be  too  strongly  condemned.  Many  a  dyspeptic  owes  his  trouble  to  over- 
feeding by  a  too  good  mother  or  nurse.  When  cream  is  added,  and  the  pro- 
portion of  fat  or  protein  is  too  large,  vomiting  will  result.  Stuffing  delicate 
children  with  cream,  regardless  of  their  digestive  power,  cannot  be  too 
strongly  condemned.  When  improper  food  is  given,  and  the  infant's  stom- 
ach is  overtaxed,  the  excess  of  food  irritates  and  may  cause  vomiting.  If, 
however,  the  food  remains,  then  the  gastric  mucosa  is  inflamed  by  bacteria] 
fermentation  of  stagnant  food.  This  may  result  in  diarrhoea  or  in  fermen- 
tative gastritis,  and  cause  chronic  enlargement  of  the  stomach. 


CHAPTER  III. 
•  HOME  MODIFICATION  OF  MILK. 

Bottle-feeding  or  Hand-feeding. 

The  following  utensils  are  required  for  the  home  modification  of 
milk : — 

Two-quart  pitcher,  "] 

Funnel,  V  glass  or  porcelain. 

One  large  spoon,      J 

One  dozen  4-ounce  bottles  (later  substitute  8-ounce  bottles) . 

One  dozen  anticolic  nipples. 

One  box  non-absorbent  cotton. 

One  saucepan  (for  heating  milk). 

One  high  saucepan  (for  warming  bottle  before  feeding). 

FJieding-bottles. 

A  proper  feeding-bottle  is  one  that  has  no  corners  or  angles  on  the 
inner  surface.  The  bottom  should  be  rounded,  so  that  every  part  of  the 
same  can  be  properly  cleaned.  Bottles  that  have  corners  and  grooves  will 
harbor  bacteria. 

My  preference  has  always  been  for  two  kinds  of  bottles:  1.  Those 
holding  4  ounces  and  graduated  on  one  side  in  both  ounces  and  tablespoons ; 
this  saves  much  time  and  trouble.  2.  Bottles  holding  8  ounces  and  divided 
off  into  16  tablespoonfuls  or  8  equal  ounces. 

Exactness  of  Ounces. — It  may  not  be  out  of  place  to  ask  each  physician 
to  insist  on  having  the  graduated  ounces  on  an  infant's  feeding-bottle  meas- 
ured with  an  accurate  graduate,  obtainable  at  every  drug  store.  In  many 
instances  the  author  noted  feeding-bottles  wherein  the  ounces  indicated 
were  very  unequal,  and  one  particular  bottle,  graduated  to  8  ounces,  held 
12  ounces. 

Long  Rubber  Tubes. — Most  prominent  podiatrists  agree  that  the  long 
rubber  tubes  are  a  convenient  place  for  harboring  micro-organisms,  and  they 
have  been  universally  condemned. 

Care  of  the  Bottle. — Every  bottle  should  be  thoroughly  cleaned  with 
a  brush  and  a  solution  of  baking  soda  and  water,  a  teaspoon  of  soda  to  a 
pint  of  water.  The  bottles  must  then  be  thoroughly  rinsed  with  clear  water. 
If  milk  has  fermented  or  if  some  residue  adheres  to  the  bottle  and  the  same 
cannot  be  properly  cleaned,  then  boiling  the  bottles  will  be  necessary.  In 
general  and  for  daily  use  the  bottle  need  not  be  boiled  every  day. 
(150) 


FEEDING-BOTTLES. 


151 


Proper  Time  for  Gleaning  Bottles. — The  best  time  to  clean  a  bottle  is 
immediately  after  the  baby  has  been  fed;  this  prevents  the  food  souring 
in  the  bottle,  and  it  is  very  easily  cleaned. 

The  bottle  brush  has  a  long  handle  and  bristles  for  cleansing  the  bottles. 
This  brush  should  be  used  before  the  bottles  are  put  into  the  soda  solution. 
It  is  understood  that  the  brtish  can  itself  harbor  bacteria  and  particles  of 
milk  removed  while  cleansing.  It  is  therefore  understood  that  the  brush 
must  be  thoroughly  boiled  in  a  soda  solution  after  each  use. 

Choice  of  a  nipple  is  another  important  matter.  My  preference  has 
always  been  for  a  black-rubber  nipple,  and  it  is  a  very  wise  point  to  use  a 
nipple  no  longer  than  one  week ;  in  other  words,  old,  worn  nipples  are  useless 
for  the  proper  management  of  infant-feeding.    Black  rubber  is  softer  than 


Fig.  49  Fig.  50 

Fig.   49. — Author's  Choice  of  Feeding-bottle. 

Fig.  50. — Bottle  Warmer.     A  convenient  bottle  warmer,  adapted  for 
keeping  the  night  feeding  warm,   is  here  illustrated.     It  is  made  by  the 
Arnold  Sterilizer  Co.     It  is  also  useful  when  traveling. 


white  rubber ;  most  white  rubber  is  supposed  to  contain  lead ;  hence  ,  a 
decided  reason  for  not  using  it. 

Nipples  Recommended. — One  of  the  best  nipples  made  is  the  so-called 
anticolic  nipple.  This  nipple  has  a  ball-shaped  top,  which  enables  a  baby 
to  take  a  firm  hold;  it  has  three  small  holes,  which  give  an  easy  flow  of 
milk,  and  regulate  a  slow  meal.  Nipples  having  very  large  openings,  which 
will  permit  a  baby  to  finish  a  6-  or  8-  ounce  bottle  of  food  in  five  or  six  min- 
utes, are  useless,  and  this  gulping  of  food  is  really  the  cause,  or  one  of  the 
causes,  of  infantile  colic. 

I  have  used  another  nipple,  but  it  is  much  harder  to  clean,  and  unless 
all  precautions  for  sterilization  are  carefully  noted  it  should  not  be  used; 
yet,  in  the  hands  of  the  intelligent  or  where  we  have  a  trained  nurse,  it  ct^n 


152 


NUTRITION. 


be  safely  recommended.  It  is  called  the  "Mizpah."  This  nipple  has  also 
a  very  small  puncture,  so  that  the  baby  gets  the  food  slowly. 

The  "swan-bill'^  nipple  and  the  long  French,  nipple  I  also  like.  I  have 
noted  just  as  good  results  as  with  the  above-mentioned  kinds. 

Ventilated  Nipple. — A  nipple  very  highly  spoken  of  is  the  ventilated 
nipple  made  by  Ware,  of  Philadelphia,  which  has  a  small  opening  or  valve 
on  the  side,  and,  as  the  milk  is  drawn  in  from'  the  bottle,  it  permits  air  to 


^\l 


'Ail   i\A 


Fig.  51.— Bottle-brush. 


enter,  thus  preventing  a  vacuum  from  being  formed.  It  is  also  supposed  to 
be  non-collapsible,  and  is  highly  recommended  by  those  who  have  used  it. 
The  only  objection — already  offered— is  that  all  nipples  must  not  only  be 
practical  for  use,  but  must  be  capable  of  thorough  sterilization. 

Cleaning  the  Nipples. — The  prevention  of  stomatitis  and  mouth  affec- 
tions depends  upon  proper  hygiene  of  the  nipple.  It  does  not  require  much 
time  or  trouble  to  remove  the  nipple  from  a  bottle  and  throw  it  into  hoiling 
water  immediately  after  using,  wrap  in  sterile  cheesecloth,  and  keep  in  a 
covered  jar.    A  nipple  thus  treated  is  properly  sterile. 


Fig.  52. — Anticolic  Nipple. 

The  nipple  sterilizer  (see  Fig.  53)  is  a  very  convenient  little  arrange- 
ment made  by  Ware,  of  Philadelphia.  It  serves  the  purpose  admirably  for 
the  sterilization  of  nipples. 


Sterilization  of  Milk. 

When  Soxhlet  first  announced  the  method  of  sterilization,  he  awoke  the 
profession  to  the  realization  of  the  dangers  lurking  in  crude  cows'  milk 


STERILIZATION  OF  MILK.  I53 

His  aim  was  to  destroy  pathogenic  bacteria,  and  give  the  infant  a  milk 
which  did  not  contain  living  bacteria. 

In  order  to  sterilize  milk,  according  to  Soxhlet,  we  must  heat  milk 
to  a  temperature  of  212°  F.  and  continue  this  steaming  for  thirty  minutes. 
We  know  that  heating  milk  produces  many  changes,  some  of  which  are 
not  thoroughly  understood.     Other  changes  have  been  positively  proven. 

Changes  in  Milk  Caused  by  Sterilization. — In  some  experiments  made 
by  Dr.  E.  M.  Hiesland  and  published  by  Dr.  B.  C.  Hirst/  it  was  found  that 
by  sterilization : — • 

1.  The  albumin  is  coagulated. 

2.  Casein  is  less  readily  precipitated  by  rennet  than  in  normal  milk. 

3.  Fat  is  freed  to  a  slight  extent;  fat  not  freed  has  a  lessened  tend- 
ency to  coalesce. 


Fig.  53; — Nipple  Sterilizer. 


4.  Sugar  undergoes  some  change,  as  shown  by  its  lessened  dextrorota- 
tory power. 

The  considerations  suggested  by  the  foregoing  facts  are: — 

1.  The  coagulation  of  milk-albumin  by  sterilization  may  render  the 
milk  more  difficult  of  digestion. 

2.  Sterilization  interferes  with  the  coagulability  of  milk  by  rennet, 
and  presumably,  therefore,  with  its  digestibility  by  the  gastric  juice. 

3.  Free  fat,  as  found  in  sterilized  milk,  is  probably  not  readily  assimi- 
lated in  infant  food.  The  fat  not  free,  being  inclosed  in  a  less  easily 
destructible  envelope,  is  probably  slow  of  digestion.^ 

On  the  question  of  sterilized  milk  the  weight  of  evidence  seems  to  show 
that  the  process,  while  preventing  undue  fermentation,  so  changes  certain  of 
the  natural  ferments  and  some  of  the  fats  that  the  milk  is  less  easily 
digested  and  less  nutritious.^ 

The  sterilization  of  milk  is  advocated  chiefly  to  destroy  pathogenic 
bacteria.  The  profession  has  been  educated  to  the  belief  that  we  must  kill 
all  livins;  micro-organisms  in  food. 


^Medical  News,  January  31,  1891. 
'Medical  Record,  February  28,  1891. 

'North  American  Practitioner,  June,  1892,  from  the  "Year-book  of  Treatment" 
(Lea  Brothers  &  Co.). 


154  NUTRITION. 

When  the  method  was  first  advocated,  the  profession  adopted  it  in  all 
parts  of  the  world;  so  that  thousands  of  babies  have  been  brought  up  on 
sterilized  milk.  Within  the  last  few  jea.rs  sentiment  has  changed.  Sterili- 
zation accomplishes  the  destruction  of  pathogenic  bacteria,  but  it  also  pos- 
sesses certain  disadvantages. 

The  spores  of  pathogenic  bacteria  cannot  be  destroyed  by  the  ordinary 
process  of  sterilization. 

To  properly  sterilize  milk  it  is  necessary  to  subject  it  to  the  process  of 
tyndallization.  This  will  render  milk  germ-free.  This  latter  process  con- 
sists of  subjecting  the  milk  to  the  process  of  sterilization  for  at  least  twenty 
to  thirty  minutes  on  three  successive  days.  For  practical  purposes  it  is 
useless. 

The  chemical  changes  produced  in  milk  by  the  process  of  sterilization 
are  as  follows:  The  lactalbumin  coagulates  at  a  temperature  of  160°  F. 
(70°  C).  Thus  the  temperature  being  212°  F.  renders  this  ingredient 
decidedly  different  from  what  it  appears  in  its  raw  state;  the  casein  is 
rendered  less  coagulable  by  rennet  and  appears  to  be  acted  upon  more  slowly 
both  by  pepsin  and  trypsin;  the  organic  phosphorus  is  changed  into  an 
organic  phosphate;  citric  acid  is  partially  precipitated  as  calcium  citrate, 
and  some  lime  salts,  which  are  usually  soluble,  are  converted  into  insoluble 
compounds. 

Certain  changes  also  occur  in  the  fat.  Moreover,  certain  natural  fer- 
ments in  fresh  milk,  believed  to  be  of  value  in  digestion,  are  destroyed  by 
heat. 

Many  of  these  changes  are  but  imperfectly  understood,  and  some  of 
them  are  doubtless  without  any  injurious  effect  upon  nutrition.  There  is, 
however,  one  important  clinical  reason  for  believing  that  the  nutritive 
properties  of  milk  are  impaired  by  heating  to  212°  F.,  viz.,  the  occurrence 
of  scurvy  in  infants  who  are  fed  upon  such  milk  for  a  long  time  (Holt). 

We  know  that  a  great  many  children  fed  on  sterilized  milk  develop 
scurvy.  The  same  is  true  of  children  fed  on  boiled  milk.  The  reason  is, 
Eundlett  so  ably  says:  "Changes  take  place  not  in  the  albumin,  fat,  nor 
sugar,  but  in  the  albuminate  of  iron,  phosphorus,  and  possibly  in  the  fluorine 
vital  changes  take  place.  These  albuminoids  are  certainly  in  the  milk,  de- 
rived as  it  is  from  tissues  that  contain  them,  and  are  present  in  a  vitalized 
form  as  proteins."  On  boiling,  the  change  taking  place  is  simply  due  to 
the  coagulation  of  the  globulin,  or  protein  molecule,  which  splits  away  from 
the  inorganic  molecule,  and  thus  renders  it,  as  to  the  iron  and  fluorine, 
unabsorbable  and,  as  to  the  phopphatic  molecule,  unassimilable.  This  is 
the  change  that  is  so  vital,  and  this  only  takes  place  when  milk  is  boiled. 

It  is  evident  that  children  require  phosphatic  and  ferric  proteins  in 
a  living  form,  which  are  only  contained  in  raw  milk. 

Cheadle  says  that  phosphate  of  lime  is  necessary  to  every  tissue;  no 


STERILIZED  MILK.  155 

cell  growth  can  go  on  without  earthy  phosphates;  even  the  lowest  form  of 
life — such  as  fungi  and  bacteria — cannot  grow  if  deprived  of  them.  These 
salts  of  lime  and  magnesia  are  especially  called  for  in  the  development  of 
the  bony  structures. 

Avoidance  of  Scurvy. — Since  clinical  experience  has  demonstrated  that 
the  prolonged  use  of  sterilized  milk  and  boiled  milk  will  produce  scurvy, 
and  that  improvement  is  immediately  noted  when  raw  milk  is  given,  or 
raw  muscle  juice  (beef-juice)  or  raw  white  of  egg,  added  to  fresh  fruit 
juices,  does  it  not  seem  more  plausible  to  commence  feeding  at  once  with 
raw  milk  rather  than  after  scurvy  or  rickets  is  developed? 

There  is  a  certain  deadness,  or,  to  put  it  differently,  absence  of  fresh- 
ness, that  is  lacking  in  milk  that  has  been  boiled  or  sterilized,  just  as  it  is 
the  absence  of  fresh  meats  and  green  vegetables  which  is  known  to  cause 
scurvy  in  the  adult. 

In  my  own  practice  I  have  so  frequently  been  disappointed  in  the  use 
of  sterilized  milk  that  within  the  last  few  years  I  have  entirely  discarded 
its  use. 

The  Disadvantages  of  Sterilized  Milk  From  a  Clinical  Standpoint. — 
The  first  effect  of  using  sterilized  milk  is  that  the  child  will  be  con- 
stipated. It  is  for  this  reason  decidedly  objectionable.  It  is  wise  to  re- 
member that  one  of  the  earliest  symptoms  of  rickets  is  constipation.  We 
have  known  that  the  prolonged  use  of  sterilized  milk  results  in  rickets. 
The  symptom  of  constipation  should  therefore  be  looked  upon  not  as  a 
temporary,  but  as  a  permanent,  damage  to  the  body.  Therefore,  it  should 
not  be  neglected.  Appropriate  dietetic  treatment  can  easily  modify  con- 
stipation. Clinicians  all  agree  that  the  prolonged  use  of  sterilized  milk 
cannot  be  advocated.  There  may  be  individual  children  who  thrive  on 
prolonged  use  of  sterilized  milk,  and  I  dare  say  on  any  form  of  feeding. 
We  are  dealing,  however,  with  average  children,  and  these  all  show  a  cer- 
tain train  of  symptoms. 

Constipation  of  the  most  stubborn  kind  will  be  encountered  in  all 
children  fed  on  sterilized  milk.  This  condition  exists  regardless  of  the 
season  of  the  year.  Children  do  not  thrive  as  well  on  sterilized  milk  as  they 
do  on  milk  subjected  to  a  much  lower  degree  of  temperature.  Sterilized 
milk  is  rendered  less  digestible  than  it  is  in  its  raw  state. 

Freeman^  says  that  the  modifications  produced  in  milk  heated  to  212° 
F.  consist  in  the  starch-liquefying  ferment  being  destroyed,  the  casein 
being  rendered  less  coagulable  and  therefore  being  acted  upon  slowly  and 
imperfectly  by  pepsin  and  pancreatine,  and  the  milk-sugar  being  destroyed. 

Fayel,^  discussing  boiled  milk,  says  that  it  is  more  indigestible  and 
in  no  respect  safer  than  unboiled  milk.    The  temperature  at  which  it  boils 


^  Paper  read  at  Academy  of  Medicine,  New  York,  May  11,  1893. 
=*  Medical  Age,  September  25,  1893. 


156  NUTRITION. 

is  insufficient  to  destroy  microbes,  and  the  milk  is  therefore  not  ster- 
ilized. Its  density  is  increased  by  the  boiling,  above  that  suitable  for  infant 
digestion. 

Milk  consists  of  a  multitude  of  cells  suspended  in  serum.  The  cells 
are  fat  cells,  which  form  the  cream.  The  remaining  cells  are  nucleated  and 
of  the  nature  of  white  corpuscles.  The  serum  consists  of  water  in  which 
is  dissolved  milk-sugar  and  serum  albumin,  with  various  salts  and,  chief 
of  all,  casein.  The  cells,  with  the  exception  of  fat  corpuscles,  are  all  living 
cells,  and  they  retain  their  vitality  for  a  considerable  time  after  the  milk 
is  drawn  from  the  mammary  glands.^ 

There  is  reason  for  supposing  that  when  fresh  milk  is  ingested  the 
living  cells  are  at  once  absorbed  without  any  process  of  digestion,  and  enter 
the  blood-stream  and  are  utilized  in  building  up  the  tissues.  The  casein 
of  the  milk  is  digested  in  the  usual  way  as  other  albuminoids  by  the  gastric 
juice,  and  absorbed  as  peptone.  There  is  also  absorption  of  serum  albumin 
by  osmosis.  The  chemical  result  of  boiling  milk  is  to  hill  all  the  living  cells 
and  to  coagulate  all  the  albuminoid  constituents.  Milk  after  boiling  is 
thicker  than  it  was  before. 

The  physiological  results  are  that  all  the  constituents  of  the  milk  must 
be  digested  before  it  can  be  absorbed  into  the  system;  therefore,  there  is 
distinct  loss  of  utility  in  the  milk,  because  the  living  cells  of  fresh  milk 
do  not  enter  into  the  circulation  direct  as  living  protoplasm  and  build  up 
the  tissues  direct,  as  they  would  do  in  fresh,  unboiled  milk.  In  practice  it 
will  have  been  noticed  by  most  medical  practitioners  that  there  is  a  very 
distinctly  appreciable  lowered  vitality  in  infants  which  are  fed  on  boiled 
milk.  The  process  of  absorption  is  more  delayed  and  the  quantity  of  milk 
required  is  distinctly  larger  for  the  same  amount  of  growth  and  nourish- 
ment of  the  child  than  is  the  case  when  fresh  milk  is  used. 

Vaughan  does  not  believe  that  railk  is  benefited  by  either  sterilization 
or  pasteurization,  but  such  procedure  is  necessary  when  market  milh  is  used, 
because  the  latter  is  seldom  or  never  obtained  under  aseptic  precautions. 

Some  people  have  an  idea  that  it  matters  not  how  flUhy  a  cow's  milh 
is,  or  how  many  germs  it  may  contain,  if  it  be  pasteurized  or  sterilized  it 
then  becomes  a  fit  food  for  children.  This  is  not  true,  because,  in  the  first 
place,  even  prolonged  boiling  does  not  kill  the  spores  of  all  bacteria,  and, 
in  the  second  place,  the  chemical  poisons  produced  by  certain  germs  are  not 
altered  by  the  temperature  of  boiling  milk. 

After  milk  has  been  either  sterilized  or  pasteurized  it  should  be  kept 
at  a  low  temperature  before  being  fed  to  the  child.  This  should  be  regarded 
as  a  necessary  procedure  in  the  preparation  of  infant  food.  The  fact  that 
milk  in  which  the  colon  germ  has  already  grown  abundantly  cannot,  by 
any  process  of  sterilization  or  pasteurization,  be  rendered  fit  food  for  chil- 


J.  L.  Kerr,  British  Medical  Journal,  December,  1895. 


PASTEURIZED  MILK. 


157 


dren  should  be  emphasized.  The  toxin  of  the  colon  hadllus  may  he  heated 
to  180°  C.  {356°  F.)  for  half  an  hour  without  having  its  poisonous  prop- 
erties diminished.  If  clean  milk  he  ohtained  and  heated  at  1^0°  F.  to  150° 
F.  for  ten  to  fifteen  minutes  and  then  kept  at  a  low  temperature  until  fed 
to  the  child,  it  furnishes  the  hest  food  tvhich  it  is  possible  for  u.s  to  ohtain 
under  ordiua/ry  circumstances. 


Pasteurization. 

Pleating  milk  to  75°  C,  as  is  done  by  many  of  the  methods,  does  not 
sterilize,  for  the  spores  of  the  bacillus  subtilis  can  withstand  this  temperature 
for  several  days.  The  spores  will  resist  the  temperature  of  100°  C.  (212° 
F.)  for  six  hours.  Upon  heating  to  110°  to  120°  C.  (230°  to  248°  F.) 
the  milk  will  be  thoroughly  sterilized,  but  such  heating  causes  a  browning 
of  the  milk,  and  the  cream-cells  are  apt  to  be  broken  and  the  fat  or  butter 
will  rise  to  the  surface. 

Pasteurization  with  a  temperature  between  60°  and  80°  C.  (140°  to 
176°  F.)  destroys  tubercle  bacilli  and,  according  to  Van  Geuns,  destroys 
also  the  typhoid  bacillus,  the  cholera  bacillus,  and  the  pneumococcus  of 
Friedlander,  and  also  most  of  the  ordinary  milk  germs,  and  does  not  injure 
the  milk, 

C.  H.  Stewart  gives  the  following  interesting  result  of  the  heating  of 
milk  at  various  temperatures,  and  its  result  on  the  albumin : — 

Table  No.  21. 


Time  of  Heatingr. 

Soluble  Albumin 
in  Fresh  Milk. 

Soluble  Albumin 
in  Heated  Milk. 

10  minutes  at  60°  C.    ( 140°  F.) 

30  minutes  at  60°   C.    ( 140°  F. ) 

Per  Cent. 
0.423 
0.435 
0.395 
0.395 
0.422 
0.421 
0.380 
0.380 
0.375 
0.375 

Per  Cent. 
0.418 
0.427 

10  minutes  at  65°   C.    ( 149°   F.) 

30  minutes  at  65°   C.    ( 149°   F.)  .  .  .• 

10  minutes  at  70°  C.    (158°  F.) 

30  minutes  at  70°  C.    (158°  F.) 

10  minutes  at  75°  C.    (167°  F.) 

30  minutes  at  75°   C.    (167°   F.) 

10  minutes  at  80°  C.    ( 176°  F. ) 

30  minutes  at  80°   C.    (176°  F.) 

0.362 
0.333 
0.269 
0.253 
0.070 
0.050 
none 
noue 

We  can  see  that  heating  milk  at  140°  F.  for  ten  minutes  or  for  thirty 
minutes  still  leaves  about  the  same  proportion  of  soluble  albumin  as  we 
find  in  fresh  milk.  When  milk  is  heated  only  ten  minutes  at  176°  F. 
no  soluhle  albumin  remains,  while  in  fresh  milk  about  0.375  is  found. 

There  is  a  slight  taste  or  flavor  which  is  noticeable  when  milk  is 
heated  to  158°  F.  for  fifteen  minutes.  For  practical  purposes,  however, 
milk  heated  to  1^0°  F.  serves  very  well  and  has  no  taste  at  all.    Pasteuriza- 


158  NUTRITION. 

tion  of  milk  has  been  received  by  the  jDrofession  with  the  same  enthusiasm 
as  was  sterilized  milk  when  it  was  first  announced.  The  mistakes  that  have 
been  made  by  forcing  infants  to  swallow  milk  sterilized  at  a  temperature 
of  212°  F.  for  tliirty  minutes  are  evident  in  so  far  as  such  children  can 
show  a  devitalized  condition  into  womanhood  and  manhood.  Constipation 
and  rickets  are  recognized  as  associate  factors  during  sterilized  milk  feed- 
ing. The  profession  at  large  is  rapidly  departing  from  this  improper  and 
dangerous  method  of  treating  raw  milk. 

What  has  been  said  of  sterilized  milk  applies  in  a  lesser  degree  to 
pasteurized  milk.  I  have  frequently  found  cases  of  infants  fed  on 
pasteurized  milk  that  showed  the  same  symptoms,  though  in  a  milder 
degree,  than  what  we  know  to  be  true  of  sterilized  milk  feeding. 

When  my  advice  is  sought  regarding  the  utility  of  pasteurizing  milk, 
I  always  say:  You  should  pasteurize  your  milk  at  a  temperature  of  140°  to 
150°  F.,  for  ten  minutes,  if  you  do  not  know  the  source  of  your  milk  supply. 
In  New  York  certified  milk  or  guaranteed  milk  is  procured,  and  it  is  un- 
necessary to  change  the  chemical  character  of  the  milk  by  prolonged  heating. 
With  certified  milk  it  is  simply  necessary  to  use  sterile  utensils  and  warm 
the  food  to  a  little  higher  than  feeding  temperature. 

General  Eules  of  Bottle-feeding  foe  Normal  Infants. 

No  set  rule  can  be  given  for  all  infants.  Each  infant's  desires  must 
be  studied.  The  stomach  capacity  of  one  infant  may  be  6  ounces  at  the 
age  of  two  months,  while  another  equally  healthy  infant  will  be  satisfied 
with  4  ounces  at  one  feeding. 

In  the  home  modification  of  milk  our  aim  should  be  to  give  a  simple 
formula,  and  one  that  can  be  easily  understood  by  the  mother  or  nurse. 
These  formulae,  with  specific  directions  added,  should  be  written  out  by 
the  physician,  and  the  following  conditions  noted:  The  weight  of  an 
infant  to  be  taken  when  a  new  formula  is  given;  the  character,  color,  and 
frequency- of  the  stool  to  be  noted;  constipation  or  diarrhoea  supervised; 
sleep  and  general  comfort  inquired  into.  Does  the  infant  appear  satisfied 
after  its  feeding,  or  does  it  put  its  fingers  into  its  mouth  and  whine  after 
each  feeding ;  does  it  draw  up  its  legs,  is  it  flatulent ;  is  there  vomiting  after 
each  feeding,  and  is  there  frequent  eructation? 

Summary. — If  the  food  agrees  the  infant  should  be  comfortable,  have 
one  or  more  natural  stools  in  twenty-four  hours,  sleep  at  least  four  hours  at 
one  time,  and  gain  in  weight  from  4  to  8  ounces  during  the  week. 

Caloric  Method  of  Feeding. 

A  calorie  is  the  amount  of  heat  necessary  to  raise  the  temperature  of  1 
kilo.  1°  C.     The  determination  of  the  heat  energy  expressed  by  a  given 


CALORIC  FEEDING. 


159 


number  of  calories  can  be  applied  in  estimating  the  food  requirement  of 

infants : — 

1  gram  or  c.c.  of  fat  equals    9  calories 

1  gram  or  c.c.  of  sugar    equals    4  calories 

1  gram  or  c.c.  of  protein  equals 4  calories 

The  most  prominent  podiatrists  in  Europe  calculate  their  food  values 
in  calories.  My  experience  with  this  method  of  feeding  has  been  very 
satisfactory.  When  the  metric  system  of  grams  and  kilograms  is  used  the 
method  is  extremely  simple.  The  requirement  for  the  first  three  months  is 
100  calories  for  each  kilo,  of  weight,  for  the  second  quarter  year  about  90 
calories;  therefore,  an  infant  weighing  5  kilos,  requires  500  calories  in 
twenty-four  hours.  Later  on,  the  requirement  is  80  calories,  and  some 
infants  at  the  end  of  six  months  do  not  require  more  than  70  calories  per 
kilo.  Emaciated  and  premature  infants  require  120  or  more  calories  for 
each  kilo. 

The  simplest  method  of  calculating  the  given  number  of  calories  in  a 
pint  or  quart  of  food  is  as  follows : — 

The  caloric  value  of  1  ounce  of  4  per  cent,  milk  is  20;  16  times  20 
calories  equals  320  calories  to  1  pint,  or  32  times  20  calories  equals  640 
calories  to  1  quart. 

20  ounces  of  4  per  cent,  milk  20  x  20 400  calories 

12  ounces  barley  water  12  x  12 24  calories 

1  ounce    malt-soup    extract 80  calories 

504  calories 

Table  No.  22. — Foods  and  Caloric  Value  of  Each. 


Food,  1  Ounce. 


Cream    ( 16    per   cent.) 

Milk    (4  per  cent,  cream) 

Milk   (2  per  cent,  cream) 

Milk    (1   per  cent,   cream) 

Milk,    fat-free    

Whey     

Condensed   milk      

Buttermilk     

Albumin  milk    

Malt-soup    extract    

Malt-soup    (formula    as    given) 

Milk-sugar    (by   volume) 

Milk-sugar     (by    weight) 

Cane-sugar     (by    weight) 

Malt-sugar''    (by   weight) 

Barley   flour    (by   weight) 

Eice  flour   (by  weight) 

Wheat  flour   (by  weight) 


Approximate 
Caloric  Value. 


54 

20 

15 

12.5 

10 

6 

1.32 

10 

13 

80 

22 

72 
117 
117 
110 
102.5 
102.5 
102 


^  Dextrimaltose,  Mead,  Johnson  &  Co. 


160  NUTRITION. 

To  make  malt  soup : — 

Cold  water 666  parts 

Milk    (4  per  cent,  fat)    333  parts 

White   flour    50  parts 

Malt  extract    (Loefflund's)    100  parts 

Mix  flour  and  water  and  bring  to  boiJ.  Add  malt  extract,  stirring  constantly, 
and  bring  to  boil.  Lastly  add  the  milk,  stirring  constantly.  Bring  to  boil  three 
times,  in  the  mean  time  cooling  it  off  quickly  by  standing  it  in  cold  water. 

Eight  level  teaspoonfuls  of  starches  or  sugars  are  approximately  1  ounce  in 
weight. 

The  formulge  on  following  page  are  based  on  the  studied  requirements 
of  an  infant  of  normal  bodyweight,  which  is  approximately  45.5  calories  for 
each  pound  weight;  hence  an  infant  weighing  7  pounds  requires  318  calories 
in  twenty-four  hours. 

This  method  is  useful  in  controlling  the  feeding  of  infants  who  are  not 
gaining  in  weight.  We  can  increase  the  calories  up  to  the  required, 
physiological  standpoint,  so  that  this  method  is  in  some  respects  similar  to 
the  percentage  method  advocated  by  Eotch  and  others. 

Formula  No.  1  (for  an  infant  from  birth  to  three  weeks  old,  weighing 
about  7  pounds,  requirement  318  calories)  : — 

IJ  Wliole  milk    13  ounces 

Hot  water   12  ounces 

Dextrimaltose    4  drachms 

Mix  thoroughly  and  heat  in  a  saucepan  until  steam  rises.  Continue  steaming 
at  same  temperature,  five  minutes.  Divide  into  ten  bottles  of  2%  ounces  each. 
Feed  every  two  hours.  Insert  large  stoppers  of  non-absorbent  cotton  in  the  necks 
of  the  bottles.  Place  in  a  refrigerator,  but  not  on  ice.  Warm  before  feeding  by 
placing  bottle  into  a  deep  saucepan  of  hot  water  until  the  food  reaches  body 
temperature. 

Formula  No.  2  (for  an  infant  from  three  weeks  to  six  weeks  old,  weigh- 
ing about  8  pounds,  requirement  364  calories)  : — 

I^  Whole  milk  14  ounces 

Hot  water    10  ounces 

Dextrimaltose    6  drachms 

Divide  into  eight  feedings  of  3  ounces  each.     Feed  every  three  hours. 

Formula  No.  3  (for  an  infant  from  six  weeks  to  two  months  old, 
weighing  about  10  pounds,  requirement  455  calories)  : — 

ij  Whole  milk    17  ounces 

Hot  water    15  ounces 

Dextrimaltose    1  ounce 

Divide  into  eight  feedings  of  4  ounces  each.    Feed  every  three  hours. 

Formula  No.  4  (for  an  infant  from  two  to  four  months  old,  weighing 
about  11  pounds,  requirement  500  calories)  : — 


CALORIC  FEEDING. 


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162  NUTRITION. 

IJ  Whole  milk 19  ounces 

Hot  water    16  ounces 

Dextrimaltose    1  ounce 

Divide  into  seven  feedings  of  5  ounces  each.     Feed  every  three  hours. 

Formula  No.  5  (for  an  infant  from  four  to  six  months  old,  weighing 
about  12  pounds,  requirement  546  calories)  : — 

I},  Whole   milk 22  ounces 

Hot  water   14  ounces 

Dextrimaltose 1  ounce 

Divide  into  six  feedings  of  6  ounces  each.    Feed  every  three  and  one-half  hours. 

Formula  No.  6  (for  an  infant  from  six  to  nine  months' old,  weighing 
about  14  pounds,  requirement  637  calories)  : — 

IJ  Whole  milk   26  ounces 

Hot  water 14  ounces 

Dextrimaltose 1  ounce 

Divide  into  five  feedings  of  8  ounces  each.    Feed  every  four  hours. 

Formula  No.  7  (for  an  infant  from  nine  to  twelve  months  old,  weigh- 
ing about  17  pounds,  requirement  773  calories)  : — • 

IJ  Whole    milk    35  ounces 

Hot  water   ., 5  ounces 

Dextrimaltose  6  drachms 

Divide  into  five  feedings  of  8  ounces  each.    Feed  every  four  hours. 

Diet  foe  a  Child  from  One  Year  to  Fifteen  Months.^ 
The  change  from  human  milk  to  cows'  milk  sometimes  causes  gastro- 
intestinal derangement.  For  this  reason  a  careful  supervision  of  the  stools 
and  general  comfort  of  the  infant  is  required.  Knowing  the  tendency  of  the 
hard  rubber  curd  of  cows'  milk  to  develop  dyspeptic  symptoms,  it  is  advisable 
to  give  a  dose  of  castor  oil  once  every  three  or  four  days  to  eliminate  stag- 
nant residue  of  food.  Many  infants  show  a  tendency  to  constipation  when 
cows'  milk  is  fed.  Such  infants  should  receive  large  quantities  of  water, 
orange  juice,  or  prune  juice  to  stimulate  peristaltic  action.'  A  small  saucer 
of  indian  meal,  Scotch  oats,  or  corn  muffin  with  butter  will  help  to  regulate 
the  bowel.  Expressed  beef  juice,  1  ounce  given  daily,  is  well  borne  and  will 
exert  a  mild  laxative  action. 

Table  No.  24. 

6.00  A.M.     Milk,    8    ounces    (if    consti-  12.30  p.m.     Beef  or  chicken  broth  with 

pated        give        Horlick's  toast  crumbs. 

malted   milk,   3    teaspoon-  Expressed    beef    juice    over 

fuls  in  8  ounces  of  water).  baked    or    mashed    potato. 

Zwieback  or  biscuit.  4.30  p.m.     Apple     sauce     or     juice     of 

9.30  A.M.     Saucer  of  farina,  hominy,  or  orange. 

cream  of  wheat.  6.00  p.m.     Cup  of  junket. 

Cup  of  milk.  Cup  of  milk. 

Biscuit. 

^  In   the  chapter  on  "Weaning,"   I  have  already  described  in   detail   another 
method  of  substitute  feeding  for  a  child  about  1  year  old. 


DIET  FOR  A  CHILD  PROM  ONE  AND  ONE-HALP  TO  TEN  YEARS.        IQI 


Table  No.  25. 
Diet  for  a  Child  from  Fifteen  to  Eighteen  Months. 


6.00  A.M.     Milk  and  crackers. 

9.00  A.M.  If  constipated:  prune  jelly, 
apple  sauce,  or  orange 
juice. 
Add  1  teaspoonful  of  dex- 
trimaltose  to  each  cup  of 
milk. 

9.30  A.M.     Saucer    of    hominy,     farina, 
Scotch   oats,    or   cream   of 
wheat. 
Cup  of  milk. 


12  Noon.     Eight  ounces   of  beef,   lamb, 
or    chicken    broth,    thick- 
ened with  farina,  sago,  or 
homemade   noodles. 
Coddled  egg,  alternate  days; 
steamed     rice     with     ex- 
pressed beef  juice. 
Apple  sauce. 
3.30  P.M.     Cup  of  milk  or  malted  milk. 

Zwieback  or  biscuit. 
6.00  P.M.     Cup   of   custard,    junket,   or 
steamed  rice. 
Cup  of  milk. 
Biscuit. 


Table  No.  26. 
Diet  for  a  Cpiild  from  Eighteen  Months  to  Three  Years. 


6.30  A.M.     Orange  juice, 

Apple  sauce,  or 

Prune  jelly. 
7.30  A.M.     Warm  milk,   8  ounces; 

Mellin's  Food,  1  teaspoon,  or 

Eskay's   Food,    1    teaspoon; 

Zwieback    or    cracker, .  with 
butter. 
11.00  A.M.     Farina, 

Hominy, 

Cream  of  wheat. 

Oatmeal,  or 

Grape-nut,  scalded  with  hot 
milk;  in  addition,  a  cup  of 

Warm  milk,  6  ounces. 
2.00  P.M.     A  soup,  a  meat,  a  vegetable, 
and  a  cracker. 

Beef  or  chicken  soup,  thick- 
ened with  split  peas,  sago, 
rice,  or  farina. 

Drink  of  water 


Clear  broth,  with  yolk  of 
egg,  or  one  or  more  ounces 
of  expressed  beef  blood. 

Oyster  or  clam  broth. 

Joint  of  chicken. 

Broiled  halibut. 

Raw   scraped   steak. 

Chicken  jelly,  or 

Calf's-foot  jelly  (without 
wine  flavor ) . 

Baked   potato,   with   butter; 

Spinach,  or 

Carrots. 
6.00  P.M.     Crust  of  bread  or  zAvieback. 

Warm  milk,  with  white  of 
egg;   or 

Cocoa. 

Junket,  custard,  corn  starch, 
tapioca,  or  farina  pudding, 
with  each  meal. 


Diet  for  a  Child  from  Three  to  Ten  Years. 

A  child  of  3  years,  excepting  in  rare  instances,  should  not  be  fed  of tener 
than  three  times  a  day.  The  best  time  for  feeding  is :  morning  meal,  7  to 
8  a.m.;  noon  meal,  12  to  1  p.m.,  and  evening  meal,  5.30  to  6.30  p.m. 

In  rare  instances  fruit  or  a  cup  of  milk  may  be  allowed  between  the 
noon  and  evening  meal.  In  the  majority  of  cases  five  hours  are  required 
to  fully  digest  the  food  given. 


164 


NUTRITION. 


The  morning  meal  should  consist  of  a  fruit,  a  small  dish  of  cereal  with 
cream,  a  cup  of  milk,  and  a  piece  of  toast  or  crackers. 

The  noon  meal  should  consist  of  a  plate  of  soup,  a  small  portion  of  meat, 
a  small  potato,  a  vegetable,  bread,  or  crackers,  or  stale  sponge  cake,  water. 

The  evening  meal  should  consist  of  an  egg  or  pudding,  a  cup  of  cocoa 
or  milk,  crackers  or  bread  with  butter  or  honey. 

It  is  safer  to  give  a  light  meaP  in  the  evening  rather  than  load  the 
stomach  with  heavy  food.  The  American  custom  of  eating  dinner  at  night 
should  not  be  applied  to  children. 

That  milk  is  very  absorptive  is  well  recognized.  It  is  a  bad  precedent 
to  store  it  away  in  refrigerators,  unless  it  is  placed  in  sealed  jars,  apart 
from  foods  which  exude  odor. 

Selection  can  be  made  from'  the  following  dietary : — 


Table  No.  27. 


MOBNING  MEAL. 


Fruit- 
Raw,  stewed,  or  baked  apple. 

Grapes. 

Grapefruit. 

Oranges. 

Cherries. 

Peaches. 

Banana. 

Stewed  prunes. 
Cereals — 

Hominy. 

Oatmeal. 

Farina. 

Force,  or 

Wheat  Flake  Celery  Food. 


Cereals — 

Shredded  wheat. 

Cream  of  wheat. 

Wheaten  grit. 

Arrowroot. 

Cerealine. 

Yellow  indian  meal. 

WTiite  indian  meal. 

Wheat  flakes. 
Buttered  toast. 
Albert  cakes. 
Zwieback. 

Vienna  bread  and  butter. 
Egg  in  any  form. 


NOON  MEAL. 


Meat    or    chicken    soup,    thickened   with 

lentils,  peas,   split  peas,  sago,  farina, 

rice,  or  egg. 
Meat — 

Broiled  chop,  steak,  or  fish. 

Chicken. 

Stewed  tripe. 

Sweet-bread. 

Raw  scraped  beef. 

Roast  beef. 

Ham  or  bacon. 


Lamb. 

Bone  marrow. 
Baked  or  mashed  potatoes,  spinach,  peas, 

beans,    tomatoes,    cauliflower,    carrots, 

asparagus,     rhubarb,     cranberries,     or 

celery. 
Apple  cider,  buttermilk,  kumyss,  seltzer, 

lemonade,  or  very  weak  tea. 
Stale  sponge  cake. 
Lady  fingers. 
Nuts. 


^Horlick's  Food  Co.  makes  a  malted  milk  lunch  tablet,  coated  with  chocolate, 
that  is  nutritious  and  digestible.  They  are  especially  indicated  when  small  meals 
should  be  given. 


DIFFICULT  FEEDING  CASES.  165 

EVENING  MEAL. 

Crackers  and  milk.  Calf's-foot  jelly  without  wine. 

Custard.  Junket. 

Cornstarch  pudding.  Oysters. 

Corn  raufFins.  Boiled,  scrambled,  or  poached  eggs. 

Farina  pudding.  Cream  of  barley. 

Milk  toast.  Cream  of  rice. 

Tapioca  pudding.  Cocoa  and  milk. 

Chicken  jelly  without  wine.  Toast  or  crackers. 

Ai-ticles  of  Food  Which  Should  be  Forbidden  TJntil  After  the  Tenth  to 
Twelfth  Year. — Fruit:  All  dried  fruits  (with  the  exception  of  prunes), 
preserved  fruits,  fruits  out  of  season,  over-ripe  fruits  or  under-ripe  fruits. 

Meats. — Pork,  sausages,  kidneys,  duck,  and  goose. 

Vegetables. — Cabbage,  radishes,  cucumbers,  turnips,  and  eggplant. 

Drinks. — Coffee  and  ice-cream  soda. 

All  candies,  pies,  and  salads  must  be  forbidden. 

Difficult  Feeding  Cases. 

If  vomiting  or  eructations  follow  the  use  of  whole  milk,  skim  off  the 
cream  and  use  the  skimmed  milk  in  the  same  dilution  as  we  formerly  used 
the  whole  milk.  If  after  changing  from  whole  milk  to  skimmed  milk  the 
same  condition  continues,  sugar  should  be  discontinued.  If  the  weight 
remains  stationary  and  the  general  symptoms  are  good,  we  must  increase 
the  carbohydrate.  For  an  infant  under  six  months,  the  addition  of  %  to  1 
drachm  of  malt-sugar  to  each  feeding  will,  if  properly  metabolized,  increase 
the  weight.  If  the  infant  is  over  six  months,  the  addition  of  malt-soup  or 
malt  extract  in  I/2  to  1  drachm  doses  to  each  feeding  will  increase  the  weight. 
In  like  manner  a  saucer  of  farina,  hominy,  or  oatmeal  steamed  with  water 
and  served  with  1  teaspoonful  of  malt-soup  will  increase  the  weight.  If 
loose  bowels  and  foul-smelling  stools  exist,  fat-free  milk  should  be  fed.  It  is 
in  this  class  of  cases  the  virtues  of  Finkelstein's  eiweiss  milch  will  be  noted. 

A  study  of  the  infant  that  does  not  assimilate  its  food  requires  a  de- 
tailed examination  of  the  skin  to  see  if  an  eczema  is  present.  We  should 
also  study  the  muscular  development  to  see  if  the  muscles  are  flabby;  note 
perspiration.  The  anus  and  buttocks  inspected  for  excoriation  and  ery- 
thema; likewise  the  mouth  examined  for  stomatitis.  The  tongue  should  be 
lifted  to  see  whether  or  no  the  fra-num  is  adherent.  The  body  weight  should 
be  taken,  the  heart  and  lungs  examined.  The  presence  or  absence  of  dis- 
tention of  the  abdomen,  the  size  of  the  liver,  and  special  symptoms,  such  as 
vomiting,  colic,  and  the  frequency  and  character  of  stools,  should  be  noted. 
The  general  comfort  of  the  baby,  whether  restless  or  quiet  at  night,  and  its 
condition  after  taking  the  feeding  are  important  guides.  Thus  only  can  we 
interpret  the  condition,  and  give  intelligent  advice. 


166  NUTRITION. 

Some  infants  have  gastric  disturbance  with  milk  in  any  of  its  dihitions. 
This  applies  to  fat-free  milk,  to  diluted  whole  milk,  or  diluted  cream.  In 
such  cases  the  alkaline  milk,  malt,  and  wlieat  modification,  known  as  Keller's 
malt-soup,  will  usually  be  tolerated.  Try  feeding  4  ounces  of  malt-soup  every 
three  hours.    If  it  agrees,  increase  1  .ounce  each  day  until  G  ounces  are  given 

at  each  feeding. 

kellee's  maxt  soup. 

Take  of  wheat  flour  2  ounces  and  add  to  it  11  ounces  of  milk.  Soak  the  flour 
thoroughly  and  rub  it  through  a  sieve  or  strainer. 

Put  into  a  second  dish  20  ounces  of  water,  to  which  add  3  ounces  of  malt 
extract;  dissolve  the  above  at  a  temperature  of  about  120°  F.,  and  then  add  2% 
drachms  of  11  per  cent,  potassium  bicarbonate  solution. 

Finally,  mix  all  of  the  above  ingredients  and  boil.  This  gives  a  food  contain- 
ing: albuminoids,  2.0  per  cent.;  fat,  1.2  per  cent.;  carbohydrates,  12.1  per  cent. 
There  are  in  this  mixture  0.9  per  cent,  of  vegetable  proteins. 

PLOUR-BALL   FEEDING. 

The  old-fashioned  flour-ball  is  a  valuable  adjunct  in  malnutrition.  A 
teaspoonful  of  the  flour  added  to  equal  quantities  of  milk  and  water  is  easily 
assimilated  and  will  be  tolerated  by  very  feeble  infants. 

In  a  dyspeptic  infant  suffering  with  frequent  vomiting  and  atrophy  due  to 
the  loss  of  food,  the  addition  of  1  and  later  2  teaspoonfuls  of  baked  wheat-flour 
to  each  feeding  was  followed  by  an  increase  in  weight,  comfortable  nights,  yellowish, 
well-digested  stools,  and  general  improvement.  After  one  month  the  gain  in  weight 
was  over  1  pound.  After  two  months  of  such  feeding  the  infant  was  able  to  assimi- 
late other  starchy  foods,  such  as  arrowroot  and  cornstarch. 

Flour-ball  food  is  known  commercially  as  imperial  granum.  It  is  made 
as  follows : — 

Tie  3  or  4  pounds  of  wheat-flour  in  a  muslin  bag  or  several  layers  of 
cheesecloth,  drop  into  boiling  water,  and  boil  for  five  hours.    Eemove  from 
the  water,  and  bake  in  an  oven  until  hard  and  dry.     After  cooling  it  is 
broken  open,  the  rind  rejected,  and  grated  into  a  powder. 
An  infant  one  month  old  should  receive : — 

Milk    1  ounce 

Water    2  ounces 

Flour-ball    2  teaspoonfuls 

Feed  every  two  to  three  hours. 

For  an  infant  six  months  old : — 

Milk 4  ounces 

Water    4  ounces 

Flour-ball   1  teaspoonful 

Dextrimaltose    1  teaspoonful 

Feed  every  four  hours. 

Eub  up  the  grated  flour-ball  with  a  little  water;  gradually  add  the  full 
quantity,  the  milk,  and  the  dextrimaltose.    Heat  until  the  steam  rises. 


DEXTRINIZED  FOOD.  167 


Dextrinized  Gruels. 


Method  of  Dextrinizing. — Prepare  the  wheat,  barley,  oatmeal,  or  rice 
flour  by  adding  a  tablespoonful  of  the  same  to  a  pint  of  water,  adding  a 
pinch  of  salt,  and  boiling  the  same  for  from  fifteen  minutes  to  one  hour. 
This  will  make  a  gelatinous  solution,  and  hence  the  name  of  barley  jelly, 
rice  jelly,  oatmeal  jelly,  or  wheat  jelly.  We  allow  this  jelly  to  cool,  and 
when  cool  enough  to  be  tasted  we  can  add  a  diastase,  such  as  cereo ;  or  taka- 
diastase,  made  by  Parke,  Davis  &  Co.;  or  the  Forbes  diastase.  When  a 
small  quantity  of  this  diastase  is  added  to  the  jellies  above  mentioned,  they 
lose  their  thickness,  and  become  very  thin.  They  can  easily  be  strained 
through  cheesecloth,  and  some  water  added  to  make  up  for  the  loss  by 
evaporation  during  the  boiling.  This  jelly,  or  gruel,  as  it  is  sometimes 
called,  made  from  either  barley,  rice,  wheat,  or  oatmeal,  is  to  be  used  with 
the  milk  after  the  diastase  is  added.  In  certain  diseases  where  milk  is  not 
well  borne,  such  as  dyspepsia  (dyspeptic  vomiting),  or  in  summer  complaint, 
where  the  giving  of  milk  is  prohibited,  feeding  with  dextrinized  gruels  for 
several  days  will  be  found  not  only  very  useful,  but  very  healthful.  In 
making  this  dextrinized  gruel,  small  particles  will  be  seen  floating,  which 
settle  out  upon  standing.  These  particles  consist  of  the  cell  walls  and  the 
proteins  of  the  cereal,  and  cut  the  curds  of  the  milk  into  fine  pieces, 
when  the  curds  begin  to  shrink  under  the  combined  action  of  rennet  and 
acid.  In  using  this  diastase  we  aim  at  breaking  up  the  tough  curd  in  cows' 
milk  by  purely  mechanical  means. 

Homemade  Diastase  for  Dextrinizing  Food. — Henry  D.  Chapin^  de- 
scribes a  simple  decoction  of  diastase  made  as  follows :  "A  tablespoonful 
of  malted  barley  grains  is  put  into  a  cup,  and  enough  cold  water  added  to 
cover  it,  usually  two  tablespoonfuls,  as  the  malt  quickly  absorbs  some  of 
the  water.  This  is  prepared  in  the  evening  and  placed  in  the  refrigerator 
overnight.  In  the  morning  the  water,  looking  like  thin  tea,  is  removed 
with  a  spoon  or  strained  off,  and  is  ready  for  use.  About  a  tablespoonful  of 
this  solution  can  be  thus  secured,  and  is  very  active  in  diastase.  It  is  suffi- 
cient to  dextrinize  a  pint  of  gruel  in  ten  to  fifteen  minutes." 

During  the  summer,  in  the  critical  cases  of  summer  complaint  in 
which  subnormal  digestion  existed,  the  author  has  seen  very  good  results 
follow  the  administration  of  any  and  all  of  the  malt  extracts  now  in  our 
market.  Frequently  the  administration  of  a  half-teaspoonful  of  malt  extract 
to  an  infant  immediately  before  feeding  was  not  only  relished  by  the  infant 
on  account  of  the  pleasant  taste  of  the  malt,  but  certainly  aided  in  the 
assimilation  of  the  food.  Earely  was  more  than  three  teaspoonfuls  of  malt 
ordered  during  twent3^-four  hours.  Such  preparations  as  maltine  give  very 
good  results.    The  malt  extract  has  a  very  pleasant  flavor  and  is  well  borne. 


^  Journal  of  the  American  Medical  Association,  July  14,  1900. 


168  NUTRITION. 

Frequently,  when  expense  proved  an  important  item,  sufficient  dex- 
trinization  of  foods  could  be  procured  with  these  malt  preparations  above 
cited. 

Nutritional  Disturbances. 

Weight  Disturbance  (Mild). — ^There  are  four  clinical  conditions,  ac- 
cording to  Finkelstein's  classification,  in  which  disorders  of  nutrition  and 
faulty  metabolism  occur.  First  is  the  mildest  form  of  intestinal  disturb- 
ance in  which  we  find  weight  fluctuations.  In  spite  of  the  food  being  suffi- 
cient in  quantity,  there  is  no  regular  gain  in  weight.  In  addition  to  the 
fluctuation  of  weight,  the  temperature  varies,  the  appetite  is  poor,  and  the 
food  tolerance  is  lessened. 

When  a  very  rich  cream  mixture  with  high  fat  content  is  given,  the 
excess  of  fat  acts  as  an  irritant  and  causes  the  symptoms  of  fat  indigestion. 
These  are  chiefly  soap  stools  and  an  increased  ammonia  output  in  the  urine. 
Unless  this  condition  is  corrected  by  lowering  the  percentage  of  fat,  symp- 
toms pointing  to  disturbance  in  the  digestive  tract  will  appear. 

Dyspepsia  (Moderate) . — In  dyspepsia,  the  moderate  form  of  weight  dis- 
turbance, we  have  thin,  greenish  stools  containing  mucus.  The  loss  in  weight 
may  not  be  marked.  There  may  be  vomiting  and  a  slight  elevation  in  tem- 
perature. Constipation,  obstinate  and  difficult  to  relieve,  exists.  As  the 
condition  is  caused  by  excessive  fat-feeding,  the  treatment  consists  in  reduc- 
ing the  fat,  and  giving  malt-sugar  or  malt  extract  to  overcome  the  constipa- 
tion. Eestorative  treatment,  chiefly  fresh  air,  or  change  of  air  if  possible, 
will  aid  in  stimulating  this  faulty  metabolism. 

The  prime  cause  of  dyspepsia  is  overfeeding.  The  great  tendency  to 
have  large  gains  in  weight  has  led  many  to  prescribe  high  fats  and  ex- 
cessive quantities  of  carbohydrate,  chiefly  sugar.  This  excess  of  sugar  will 
in  time  give  rise  to  symptoms  of  vomiting  and  grass-green,  diarrhoeal  stools. 
The  abdomen  is  distended  and  there  is  a  slight  rise  in  temperature,  usually 
between  100°  and  101°.  The  excessive  sugar  feeding  usually  results  in 
eczema  of  the  face  or  scalp.  There  is  marked  irritation  and  erythematous 
redness  around  the  anus.  The  tolerance  for  food  is  greatly  reduced.  Finkel- 
stein  believes  that  when  the  fat  content  of  the  food  is  high  the  excess  of  fat 
causes  the  lowering  of  the  tolerance  for  sugar.  The  condition  is  frequently 
found  in  infants  fed  on  condensed  milk.  Herein  we  have  a  distinct  sugar 
disturbance,  colic  due  to  excessive  fermentation,  and  flatulence.  If  this 
condition  is  neglected  and  the  food  elements  not  corrected,  serious  results 
will  follow. 

An  infant  3  months  old,  gaining  in  weight,  with  yellow  stools,  was  suddenly 
deprived  of  its  mother's  milk  and  weaned.  It  was  fed  on  cows'  milk,  3  ounces; 
sterile  water,  3  ounces;  and  malt-sugar,  Vi  teaspoonful,  every  three  hours.  After 
three  days,  vomiting,  curded  stools,  and  flatulence  were  noted.  The  diagnosis  of 
dyspepsia  was  made.     The  formula  was  changed  to  skimmed  milk,  3  ounces;  sterile 


MALNUTRITION.  169 

water,  3  ounces;  and  malt-sugar,  %  teaspoonful.  The  symptoms  appeared  milder, 
but  continued  until  the  sugar  was  stopped,  and  equal  parts  of  sterile  water  and 
skimmed  milk  were  given.  After  one  week  ^4  teaspoonful  of  Loefflund's  malt  ex- 
tract was  added  to  every  other  feeding.  In  two  weeks  the  formula  was  increased 
to  skimmed  milk,  4  ounces;  sterile  water,  3  ounces;  and  malt-sugar,  y^,  teaspoonful. 

The  third  stage  of  nutritional  disturbance  is  decomposition  (severe),  in 
which  the  most  important  symptom  of  malnutrition  is  atrophy.  This  is 
described  elsewhere  in  extenso. 

The  fourth  stage  of  nutritional  disturbance  is  called  intoxication. 
Finkelstein  proves  that  it  is  not  the  bacteria,  but  a  failure  of  metabolism 
caused  by  an  excess  of  sugar,  and  that  milk-sugar  can  of  itself  produce  this 
intoxication.  The  removal  of  sugar  from  the  food  is  followed  by  a  cessation 
of  all  symptoms.    This  condition  is  described  elsewhere  in  detail. 

Milk  Idiosyncrasy, 

In  former  editions  of  this  book  milk  idiosyncrasy  has  been  described. 
The  reason  for  this  non-tolerance  of  milk  has  proven  very  interesting.  The 
physician  must  study  the  milk  formula  and  learn  therefrom  which  com- 
ponent of  the  food  causes  the  disturbance.  Is  it  a  high  fat  content,  as  in 
cream  feeding;  or,  is  it  a  high  sugar  content?  if  so,  try  to  remedy  the 
formula  by  a  reduction  of  fat,  or  a  reduction  of  sugar,  and  in  some  instances 
to  give  the  stomach  absolute  rest  for  twenty-four  to  forty-eight  hours.  This 
should  be  done  to  allay  gastric  irritation.  In  this  class  of  cases  malt-soup 
may  be  used  to  advantage.  In  some  cases  it  may  be  well  to  feed  1  ounce  of 
food  every  two  hours,  for  twenty-four  hours,  and  gradually  increase  the 
quantity  from  day  to  day  until  several  ounces,  at  one  feeding,  are  given.  As 
we  increase  the  food,  the  interval  between  feedings  must  be  lengthened. 
Instead  of  two-hour  intervals,  three-  or  four-  hour  intervals  may  be  demanded. 
The  diagnosis  of  true  milk  idiosyncrasy  should  not  be  made  until  after  a 
thorough  study  of  the  real  nature  of  the  disturbing  element,  and  then  only 
if  no  form  of  milk — its  dilutions  or  modifications — can  be  tolerated. 

Malnutkition  (Mabasmus). 

When  constipation  exists  and  the  infant  does  not  assimilate  its  food 
as  evidenced  by  stationary  weight,  the  addition  of  1  to  2  teaspoonfuls  of 
Loefflund's  malt-soup  extract  to  each  feeding  will  improve  this  condition.  If, 
however,  no  gain  in  weight  is  noted,  then  Loefflund's  malt-soup  feeding  may 
be  tried. 

Vomiting. — When  gastric  irritability  occurs  and  there  is  vomiting  and 
curded  stools,  the  substitution  of  a  light  food  for  a  few  days  to  one  week  is 
indicated.  Such  food  should  be  condensed  milk,  1  teaspoonful,  and  hot  water, 
6  ounces,  every  three  hours.  If  vomiting  ceases,  then  increase  to  2  teaspoon- 
fuls of  condensed  milk  and  8  ounces  of  hot  water. 


CHAPTER  lY. 

PERCENTAGE  FEEDING. 

It  is  now  many  years  since  the  Walker-Gordon  milk  laboratory  was 
established  in  New  York.  Their  method  of  feeding  infants  is  based  on 
mixing  the  ingredients  in  such  combination  that  when  combined  they 
should  resemble  certain  chemical  formulge  of  breast-milk  at  various  ages. 

Theoretically  the  percentage  feeding  advocates  are  correct;  practically 
we  cannot  successfully  feed  infants  according  to  definite  percentages.  Daily 
variations  are  important,  just  as  the  variations  in  the  human  breast  occur. 
The  simpler  the  formula^,  the  less  chance  of  contamination.  Blanks  are 
given  the  physician,  which  are  filled  out  according  to  the  individual  re- 
quirement. The  age  and  weight  are  noted.  Fat,  sugar,  protein,  and  water 
are  prescribed  in  percentages.  We  are,  therefore,  able  to  state  that  the  food 
ordered  contains  a  definite  percentage  of  fat,  sugar,  caseinogen,  and  lactal- 
bumin.  The  same  is  also  true  regarding  the  heating  of  food.  We  can  pre- 
scribe the  food  sterilized,  pasteurized,  or  raw.  Many  changes  can  be  made : 
we  can  increase  or  decrease  the  fat;  the  same  is  true  of  sugar  and  protein. 

The  quantity  of  food  prescribed  depends  on  the  requirements  of  each 
infant.  Some  infants  can  take  3  ounces  at  one  feeding,  while  others  appear 
satisfied  after  taking  2  ounces  of  food. 

Examples. — For  an  infant  at  birth: — 

Fat 2.00 

Sugar 5.00 

Protein 1.00 

Lime-water 5.00 


»  Formula  I 


Formula  II 


Milk,  raw  or  pasteurized.    Two  ounces  to  be  given  every  two  hours. 
If  the  infant  thrives,  the  ingredients  may  be  increased;  also  the  quan- 
tity at  each  feeding : — ■ 

Fat 2.50 

Sugar  . , 6.00 

Protein   1.00 

Lime-water   5.00 

Later,  if  conditions  warrant  it : — 

Fat 3.00 

Sugar 6.00 

Protein    1.50 

Lime-water   5.00 


Formula  III 


In  this  manner  we  can  gradually  increase  the  percentage  of  ingredients 
until  whole  milk  is  ordered.     When  abnormal  conditions  prevail — such  as 
loose  bowels — ^barley  water  may  be  substituted  for  the  sterile  water. 
(170) 


PERCENTAGE  FEEDING.  171 

Successful  percentage  or  laboratory  feeding  will  only  be  accomplished 
when  the  physician  is  willing  to  supervise  the  products  of  metabolism  and 
increase  or  decrease  the  ingredients  demanded  by  individual  symptoms.  For 
example:  hard,  diy,  saponified  stools  require  lower  percentage  of  fat;  a 
very  anaemic  condition,  more  fat  and  protein;  a  restless,  hungry  infant, 
immediately  after  feeding,  a  larger  quantity  of  all  ingredients. 

It  is  impossible  to  make  an  emulsion  like  milk  from  its  component 
parts  by  a  synthetic  process.  Let  it,  therefore,  be  distinctly  understood  that, 
once  a  milk  emulsion  is  broken  up,  as  is  done  in  centrifuging  milk  and 
removing  the  cream,  mixing  the  whole  will  never  restore  the  uniformity 
of  the  emulsion  that  existed  prior  to  this  division. 

In  domestic  modification,  of  course,  the  same  care  must  be  taken  to 
secure  clean,  pure  milk  and  cream  from  healthy,  well-kept  cows.  This  is 
quite  possible  now  in  New  York,  and  is  becoming  easier  each  year,  as  more 
attention  is  being  given  to  infant-feeding  and  greater  demand  is  being  made 
for  a  pure  milk  supply.  Pasteurization  is  as  readily  done  in  the  nursery  as 
in  the  laboratory.  Accurate  measurement  of  quantities  and  cleanliness  of 
vessels  and  feeding-bottles  are  equally  possible  and,  in  my  experience,  quite 
as  certain  at  home  as  in  the  shop. 

Clinical  experience  has  demonstrated  the  fact  that  some  children  will 
thrive  on  condensed  milk  in  spite  of  faulty  hygiene,  while  others  will  not 
thrive  in  the  best  environment  with  the  best  form  of  feeding;  again,  some 
children  will  thrive  on  modified  milk ;  others  will  not.  Some  cases  seen  by 
the  author  suffered  with  intense  constipation,  having  clay-colored  stools. 
In  one  instance,  in  which  two  children  in  one  family  were  constantly  fed 
on  modified  milk  of  varying  proportions,  the  formulae  were  changed  at  least 
a  half-dozen  times,  with  the  usual  increase  of  fat  and  sugar  and  lowering  of 
the  proteins,  and  in  spite  of  this  fact,  after  repeated  trials,  and  no  benefit, 
this  feeding  method  was  abandoned.  A  child  recently  seen  by  the  author 
did  not  gain  1  ounce  in  four  months.  This  was  one  of  the  reasons  that 
prompted  the  family  to  change  both  the  physician  and  the  food.  The  child, 
about  2  years  old,  was  very  pale,  restless  at  night,  quite  peevish  during  the 
day,  and  decidedly  backward  in  development.  It  could  neither  speak  nor 
walk,  although  the  teeth  were  well  developed.  From  the  time  the  modified 
milk  was  discontinued,  and  a  nitrogenous  diet  given,  the  infant  improved, 
and  from  last  reports  is  quite  well  developed. 

Do  not  let  us  blindfold  ourselves  with  the  belief  that  an  infant  is 
thriving  unless  it  shows  a  regularity  in  the  increase  of  weight',  sleeps 
well  at  night,  for  at  least  from  six  to  nine  hours  continuously,  and,  above  all, 
assimilates  its  food,  as  evidenced  by  regular,  unaided  movements  of  the 
bowels;  such  movements  should  be  once  or  twice  in  twenty-four  hours,  have 
a  yellowish-white  color,  and  a  mustard-lil'e  consistency.  If  the  stool  is  hard 
or  lumpy  or  pasty,  like  putty,  then  it  is  certainly  abnormal,  and  shows  im- 


172  NUTRITION. 

proper  food.  The  same  is  also  true  if  the  stool  contains  white,  cheesy  curds, 
showing  a  fat  indigestion.  In  one  infant,  which  had  taken  modified  milk 
continuously  for  seven  months,  an  obstinate  constipation  was  only  relieved 
after  full  doses  of  codliver-oil  and  extract  of  malt  were  given  for  several 
weeks — aided  by  massage,  besides  changing  the  diet. 

It  is,  therefore,  very  necessary  to  continually  watch  the  baby,  and  when 
abnormal  conditions  such  as  anaemia  prevail,  it  is  wise  to  give  restoratives 
for  a  long  period  in  addition  to  the  food.  Note  if  the  food  is  deficient 
in  its  nutritive  elements,  and,  if  so,  change  the  formula  so  as  to  adapt  it  to 
the  baby.  Do  not  give  medicine  when  the  quality  or  quantity  of  food  is 
deficient.    Remedy  the  food  first;  then,  if  not  satisfied,  give  medication. 

An  unusual  pallor  of  the  skin,  and  also  of  the  conjunctival  mucous 
membrane,  has  frequently  been  noticed  in  modified-milk  babies.  In  one 
instance  an  extreme  leucocytosis  was  noticed,  for  the  treatment  of  which 
iron  was  given.  An  examination  of  a  drop  of  blood  showed  a  diminution  of 
the  red  blood-corpuscles  and  an  excess  of  the  white  blood-corpuscles.  A 
decided  hgemic  murmur  was  noticeable  in  the  vessels  of  the  neck  in  a  child 
2  years  old  which  had  been  fed  continually  on  modified  milk. 

Craniotabes,  softening  of  the  cranial  bones,  as  well  as  very  late  closing 
of  the  anterior  fontanel,  have  also  been  observed  in  some  children  fed  with 
this  form  of  food. 


CHAPTER  V. 
OTHER  SUBSTITUTE  FOODS. 

Goats'  Milk. 

My  experience  with  goats'  milk  has  been  rather  good.  The  following 
case  will  serve  to  illustrate  the  manner  in  which  goats'  milk  was  used : — 

An  infant,  seven  months  old,  was  seen  by  me  in  consultation.  She  could  not 
digest  cows'  milk,  but  suffered  vomiting,  with  intestinal  colic,  and  had  cheesy  and 
curded  stools.  When  goats'  milk  was  given  in  the  same  quantity  as  cows'  milk,  the 
acute  indigestion  subsided. 

In  a  second  case,  an  infant,  one  month  old,  vomited  whenever  cows'  milk  was 
given,  and  suffered  with  dyspeptic  catarrh.  The  symptoms  subsided  when  the  infant 
was  put  to  the  breast  of  a  wet-nurse.  After  several  months  wet-nursing  the  infant 
was  again  given  cows'  milk,  and  again  the  symptoms  returned.  As  we  could  not 
procure  a  wet-nurse,  goats'  milk  diluted  with  rice  water,  using  four  ounces  of 
goats'  milk  with  four  ounces  of  rice  water,  and  one  teaspoonful  of  sugar,  was  given. 
The  child,  six  months  old,  was  fed  once  every  three  hours.  After  one  week's  feeding 
we  increased  the  quantity  of  goats'  milk  to  five  ounces  and  decreased  the  rice  water 
to  three  ounces.  When  the  child  was  nine  months  old  pure  goats'  milk,  pasteurized 
for  ten  minutes  at  a  temperature  of  158°  F.,  was  fed,  with  very  satisfactory  results. 
The  child  gained  in  weight  and  had  yellowish  stools. 

Barbellion^  has  for  years  been  an  ardent  advocate  of  the  introduction 
of  goats'  milk  for  infants  and  invalid  diet.  He  describes  tests  which  show 
that  the  coagulum  is  soft  and  very  soluble,  like  that  of  human  and  asses' 
milk,  while  the  coagulum  from  the  cows'  milk  is  more  compact  and  difficult 
to  digest.  Comparative  tests  with  gasterin  showed  that,  while  cows'  milk 
was  scarcely  affected  by  it  during  twenty  hours,  human,  goats',  and  asses' 
milk  were  completely  digested. 

He  reports  a  number  of  cases  showing  the  remarkable  manner  in  which 
infants  thrive  on  goats'  milk.  The  Academic  voted  in  favor  of  his  conclu- 
sions as  to  the  advisability  of  establishing  numerous  goat  milk  depots 
throughout  the  city.  One  of  the  principal  advantages  of  the  goat  for  this 
purpose  is  that  it  is  refractory  to  tuberculosis. 

Buttermilk  Feeding. 

A  very  elaborate  paper  on  the  subject  of  buttermilk  feeding,  by  Dr. 
Teixeira  de  Mattos,   of   Eotterdam,   has  been   published.^     He   cites   de 


^Goats'  Milk  for  Infant  Feeding.    Barbellion  (Paris).     Bulletin  de  I'Academie 
de  Medecine  (Paris). 

*  Jahrbuch  fiir  Kinderheilkunde,  January,  1902. 

(173) 


174  NumiTioisr. 

Jager,  who  published  a  paper^  reconmieiiding  -  this  form  of  feeding; 
Karger;  Houwing/  and  private  and  public  reports  of  Schlossmann, 
Heubner,  Soltmann,  Finkelstein,  de  Mattos,  and  others. 

Buttermilh. — Take  1  quart  {liter)  of  buttermilk;  add  1  even  table- 
spoonful  of  rice,  wheat,  or  other  flour  desired  {about  10  to  18  grams) ;  heat 
the  mixture  ov&i^  a  small  gas\  fire,  with  constant  stirring,  until  it  has  boiled 
up  three  different  times  {requiring  about  twenty-five  minutes) ;  then  add 
2  or  3  tablespoonfuls  {about  70  to  90  grants)  of  cane  sugar  or  beet  sugar. 
It  is  better  to  use  new  enameled  ivare  or  agate  ware  for  preparing  this  food. 
The  food  as  above  prepared  assumes  a  yellowish  color. 

It  is  necessary  to  have  wide  mouths  for  the  bottles,  as  the  food  coagulates 
and  gets  lumpy,  in  which  event  it  would  require  occasional  shaking  to  bring 
the  thickened  portion  to  the  proper  consistency. 

Bulgarian  Milk. — Milk  soured  with  either  a  pure  culture  of  the  lactic 
acid  bacillus,  or  tablets  containing  the  Bulgarian  bacillus,  must  not  be  con- 
founded with  ordinary  buttermilk.  By  the  action  of  the  lactic  acid  on  the 
casein  of  the  whole  milk,  one  transforms  the  casein  into  a  soluble  casein 
lactate. 

How  to  Prepare. — Boil  the  milk  and,  when  cool,  skim  off  the  skin  that 
rises.  To  one  quart  of  boiled  milk  add  one  teaspoonful  of  pure  culture 
of  the  lactic  acid  bacillus,  or  one  tablet  containing  such  bacillus,  made  by 
the  Fairchild  Brothers  &  Foster,  or  by  Parke,  Davis  &  Co.  Set  this 
inoculated  milk  in  a  warm  place  for  twenty-four  to  forty-eight  hours. 
The  lumpy  mixture  must  then  be  thoroughly  shaken,  and  if  of  a  thick, 
creamy  consistency  must  be  placed  in  a  refrigerator  to  retard  further 
souring. 

Graanboom,  in  his  book  on  "Diseases  of  the  Digestive  Tract  in 
Children"  (1901),  states  that  he  also  is  very  much  impressed  with  the 
value  of  buttermilk  as  an  infant-food. 

De  Mattes  states  that  children  so  fed  for  a  period  of  six  to  eight 
months  show  signs  of  rickets  or  late  dentition,  although  they  look  well 
and  appear  to  be  well  nourished.  Whether  other  methods  are  worse  he 
does  not  state. 

Lactic  acid  was  never  found  in  the  urine  of  infants  fed  either  with 
lactic  acid  or  salts.  This  series  of  experiments  was  made  by  de  Mattos, 
and  the  results  were  corroborated  by  Houwing. 

The  amount  of  lactic  acid  present  in  buttermilk  has  been  carefully 
studied.    Eobertson,  a  chemist,  found  it  to  be : — 

Minimum    0.09  per  cent. 

Maximum  0.45  per  cent. 


"■  Nederlandsch  Tydsehrift  voor  Geneeskundigebladen,  October,  1895. 
2  Centralblatt  fur  Gynakologie,  51,  190. 


BULGARIAN  MILK.  175 

De  Jager  believes  that  good  Initienuilk  does  not  contain  more  than  0.5 
per  cent,  of  free  lactic  acid.^  These  are,  however,  not  ahsolute  and  positive 
data,  hut  really  individual  hypotheses. 

Contrary  to  the  ideas  of  ]\Iunk,  Uffelmann,  and  Ewald  (who  fear  the 
use  of  food  containing  lactic  acid),  de  Mattos  has  found  that  chronic 
enteritis  and  gastric  complaints  soon  improve  when  an  exclusive  buttermilk 
feeding  is  resorted  to.  Hayem  and  Lesagc  regard  lactic  acid  as  entirely 
innocuous  for  nurslings.  According  to  the  above-named  investigators,-  lactic 
acid  is  not  toxic  for  infants.  They  gave  experimentally  15  to  20  grains  in 
divided  doses,  mixed  with  sugar,  without  seeing  any  detrimental  results. 
Jaworski"  found  no  trace  of  lactic  acid  in  an  infant's  stomach  one  hour 
after  administering  it. 

Eiel  maintains  that  lactic  acid  improves  digestion,  while  Duclaux''' 
states  that  lactic  acid  is  a  valuable  astringent.  Heubner*  found  lactic  acid 
in  the  stomach  of  two  healthy  infants  (to  the  extent  of  0.16  to  0.2  per  cent.). 
Marfan  (quoting  Zotow)  maintains  that,  when  lactic  acid  is  found  in  the 
stomach  of  infants,  it  is  always  a  pathological  factor. 

Buttermilk  in  its  crude  (raw)  state  is  certainly  antagonistic  to  other 
micro-organisms.  This  is  due  to  the  presence  of  lactic  acid  bacilli.  Eaw 
cows'  milk  possesses  bactericidal  properties,  but  buttermilk  is  much  more 
bactericidal.  The  latter,  sterilized  with  the  aid  of  steam,  showed  virulent 
typhoid  bacilli  nine  days  after  being  inoculated  with  the  same.  In  non- 
sterilized  huttermiUv  (raiv  state)  virulent  typhoid  hacilli  lost  their  virulence 
after  two  days,  and  when  put  into  the  brooding  oven  lost  their  virulence 
after  tiventy-four  hours.  The  bacillus  lacticus  of  Pasteur  and  Hueppe  seems 
to  be  identical  with  the  bacillus  lactis  aerogenes  of  Escherich,^  Avhich  is 
found  in  the  upper  part  of  the  small  intestine. 

Jaworski  found  that  pepsin  is  more  readily  secreted  when  lactic  acid 
is  given  internally.  De  Mattos  states  that  he  has  never  met  with  a  case  of 
Barlow's  disease  among  infants  fed  with  buttermilk. 

Disagreeable  symptoms  are  frequently  encountered  for  the  first  few 
weeks  while  giving  buttermilk.  Such  are  frequent  vomiting  and  diarrhcea. 
These  are  not  contra-indications  for  feeding,  and,  notwithstanding  the 
presence  of  the  above-named  symptoms,  the  feeding  should  be  continued. 
If,  however,  the  symptoms  are  very  severe,  then  the  administration  of  astiin- 
gents — such  as  bismuth,  argent,  nitrate,  tannalbin,  or  ichthalbin — may  be 
required  for  temporary  relief. 

An  important  point  is  that  in  this  fonn  of  infant-feeding  the  large, 


'  Nederlandsch  Tydscliritt  voor  Gcneoskuiidigebladt'ii,  1899,  i,  S.  94.5. 

^  Deutsches  Archiv  fiir  klinische  Mt-dicin,  Bd.  xxxvii,  i. 

'  "Maladies  de  TEnfancp,"  tome  ii,  p.  OOO. 

*"Jahrbuch  fiir  Kinderhoilkunde,"  1891. 

""Die  Darmbacterieu  des  Sauglings,"  Stuttgart,  188G, 


176  NUTRITION. 

thick,  clieesy  curds  so  commonly  met  with  in  dyspepsia  and  diarrhoeas  in 
feeding  with  cows'  milk  are  never  seen.  Children  thus  fed  seem  to  with- 
stand the  infectious  diseases  very  well.  A  point  worth  noting  is  that  when 
a  child  is  more  accustomed  to  buttermilk  feeding  the  change  to  sweet  milk 
will  cause  diarrhoea. 

When  we  find  that  the  weight  is  not  increased  and  we  desire  to  change 
to  sweet  milk,  the  latter  should  be  gradually  added  to  the  buttermilk  in- 
stead of  making  a  distinct  change  .suddenly. 

Quality  cf  the  Euttermiik. — This  is  the  most  important  part  of  our 
subject.  In  securing  our  food  we  must  be  sure  that  we  are  dealing  with 
honest  dairj'^men  whose  sole  object  is  to  deliver  what  is  demanded  for  weak 
infants.  Stale  combinations  made  by  the  use  of  left-over  centrifugal  milk 
or  skim-milk  or  spoiled  milk  which  cannot  be  used  otherwise  should  be 
inquired  into  and  rejected. 

Good  buttermilk  can  be  made  from  either  whole  milk  or  from  cream. 
In  Holland  buttermilk  is  made  by  pasteurizing  cream  in  Timpe's  apparatus 
and  then  inoculaticg  and  buttering  the  same  with  a  pure  culture  of  lactic- 
acid  bacillus.  In  order  that  raw  milk  will  yield  buttermilk  a  certain  per- 
centage of  acidity  must  be  present. 

The  usual  precautions  in  milking  (so-called  modem  stable  hygiene) 
must  be  observed  in  securing  milk  to  be  used  in  making  buttermilk.  The 
milk  should  be  received  in  sterile  vessels  and  rapidly  cooled,  and  should  then 
be  kept  in  cool  cellars  or  ice-coolers  having  a  low  temperature  (no  higher 
than  15°  or  20°  C.)  for  eighteen  to  twenty-four  hours.  It  is  necessary  to 
stir  the  milk  occasionally.  Rapidity  of  souring  can  be  assisted  by  adding 
sour  milk  or  by  inoculating  with  a  pure  culture  of  lactic-acid  bacilli.  ISTo 
definite  rule  can  be  laid  doAvn  as  to  when  buttering  takes  place;  empiric 
methods  must  decide  this  matter.  This  is  due  to  the  size  of  the  vessel  used 
and  the  influence  of  seasonal  changes,  and  also  the  amount  of  churning  it- 
had  received.  Cows'  milk  which  contains  colostrum  or  which  is  bitter  is  not 
adapted  for  buttering. 

Butter  should  form  in  small,  pin-head-sized  particles  in  thirty  to  forty- 
five  minutes.  It  is  regarded  as  a  mistake  to  have  large  particles  of  the  size 
of  a  pea  or  larger,  and  dairymen  look  upon  such  buttermilk  with  suspicion. 
Buttermilk  in  general  contains  al)Out  0.3  to  0.4  per  cent,  of  fat. 

Escherich  states  tliat  the  fermentation  of  milk  is  due  to  the  splitting 
up  of  the  milk-sugar,  whereby  lactic  acid,  0,  and  CO2.  are  formed  in  the 
intestine. 

Table  No.  38,  on  following  page,  is  instructive  in  showing  the  per- 
centage of  acidity  i)resent  and  also  the  diflterence  in  fat. 


BUTTERMILK. 


177 


T.vjJLE  No.  28. 


Specific 
Gravity. 

Solids, 
Percentage. 

Fat. 

Acidity  According 
to  Soxhlet-Henkel. 

Sour  milk  lief  ore 
buttering   • 

1.029 

11.40 

2.8 

18.1 

Buttermilk 

1.029 

9.60 

0.5 

16.1 

Tliere  is,  therefore,  a  difference  of  2  per  cent,  in  the  amount  of  acidity 
present  in  favor  of  buttermilk. 

An  important  point  is  to  overcome  ihe  lumps  vstiaJli/  fouiifl  as  coarse 
coaguJa  in  huttermill-.  De  Mattos  advises  adding  flour — eilher  rice,  wheat, 
or  lentil — or  even  some  proprietary  infant  foods,  according  to  the  require- 
ments of  the  infant. 

This  is  merely  given  to  hold  the  flocculi  in  finer  form  and  to  prevent 
their  coagulation  into  lumps.  Dyspeptic  children  with  subnormal  digestive 
powers  should  receive  a  minimal  quantit}';  thus,  an  even  tablespoonful, 
amounting  to  about  10  grams,  will  suffice. 

Addition  of  Sugar. — The  quantity  of  sugar  to  be  added  must  be  reck- 
oned empirically;  thus,  3  tablespoonfuls,  about  90  grams,  are  required  to 
each  liter  (quart)  of  buttermilk.    Earely  do  we  need  more  than  100  grams. 

Cane-sugar  or  beet-sugar  serves  best  for  sweetening.  Sugar  cannot  be 
found  in  the  urine  nor  in  the  fa?ces  of  infants  fed  on  buttermilk  to  which 
sugar  was  added. 

The  results  which  might  be  expected  from  using  cane-sugar — such  as 
diarrhoea,  fermentation,  sour  eructations — are  totally  absent  in  using  butter- 
milk feeding. 

Stools. — The  average  buttermilk-fed  infant  has  no  more  than  one  or 
two  stools  daily.  They  are  more  or  less  solid  in  consistency  and  have  an 
all-aline  reaction.  It  would  be  incorrect  to  state  that  all  children  fed  with 
buttermilk  must  have  yellow  stools.  We  know  that  even  Uffelmann,  in  his 
studies  of  infant-stools,  states  that  breast-fed  infants  show  great  variations 
from  apparent  normal  stools  and  still  thrive.  We  also  know  that  bottle- 
fed  infants  reared  on  cows'  milk  have  no  definite  l-ind  of  stool  which  we 
could  call  a  standard  stool.  Still,  the  buttermilk-fed  infant  never  has  the 
coarse  casein  particles  in  the  faeces  that  we  see  very  frequently  in  the  stools 
of  infants  fed  on  cows'  milk. 

The  bacteriological  examination  of  the  fa?ces  'made  by  inoculating 
gelatine  plates  with  diluted  fseces  showed  : — ■ 

1.  Liquefying  colonies  rendered  Loeffler's  nutrient  gelatine  strongly 
alkaline.  Inoculated  into  bouillon,  the  latter  remained  clear,  forming  a 
skim  on  the  surface.     Milk  was  not  coagulated  by  these  micro-organisms. 

12 


278  XUTRITIOX. 

They  formed  spores,  generated  H^S,  and  can  therefore  be  identified  as  the 
bacillus  but3'rieus  of  Hueppe. 

2.  Xon-liqnefying  colonies  were  inoculated  into  milk-sugar  bouillon  and 
left  in  the  brooding  oven  over  eight  hours  at  37°  C.  All  tubes  so  treated 
were  turbid  on  standing  over  night ;  this  fact  excludes  the  possibility  of  its 
being  the  bacterium  coli. 

Other  properties  were  found,  such  as:  fermentation  in  milk-sugar 
bouillon,  no  skim  f omiing  on  the  bouillon ;  indol  does  not  form  in  peptone 
solution  (bacterium  coli  would  form  indol)  ;  milk  turns  sour  but  slowly; 
no  NH3  formation. 

From  a  study  of  the  above  properties  we  conclude : — - 

1.  Bacterium  coli  commune  must  be  excluded. 

2.  Bacterium  coli  lactici  (Hueppe)  (resp.  bacterium  lactis  aerogenes, 
Escherich)  must  be  identified. 

The  lactic  acid  bacillus,  found  in  boiled  as  well  as  raw  buttermilk,  loses 
its  potency  in  the  intestinal  canal  in  the  presence  of  the  bacillus  butyricus 
(Hueppe).  The  latter  germ  grows  in  overwhelming  numbers  and  renders 
the  intestinal  contents  rapidly  alkaline. 

An  interesting  point  is  that,  if  the  buttermilk  was  originally  very 
sour,  the  faeces  w^ill  be  very  alkaline,  showing  how  weak  the  bacterium  acidi 
lactici  is. 

Feeding. — The  writer  has  seen  excellent  results  from  buttermilk  feeding 
in  atrophic  and  marasmic  children.  As  an  article  of  diet  during  convales- 
cence after  pneumonia  and  typhoid  fever  the  results  were  encouraging. 

Quantity  to  he  Fedr — ■Buttermilk  as  above  prepared  should  be  fed 
exactly  as  would  other  milk.  Four  ounces,  increased  to  5  or  6  ounces,  can 
be  fed  every  3  hours,  or  the  interval  may  be  prolonged  to  3I/2  or  -i  hours. 
It  will  be  necessary  to  coax  the  child  in  the  beginning  with  this  new  form 
of  feeding,  owing  to  the  difference  in  the  taste  of  fresh  milk  and  butter- 
milk. 

Lahmann's  Vegetable  Milk. 

In  Europe,  and  recently  also  in  our  country,  the  feeding  of  infants  has 
been  enriched  with  a  new  product;  thus,  Dr.  Lahmann  believes  that  the 
great  panacea  is  feeding  infants  with  milk  which  he  designates  as  '•'vege- 
table milk."  It  resembles  a  thick  jelly,  and  is  made  by  Hewwel  &  Veithen, 
of  Cologne.  His  theory  consists,  in  brief,  in  substituting  nuts  and  almonds, 
which  are  rich  in  albumin  and  fat,  instead  of  cereals  to  dilute  milk,  his 
idea  l>eing  that  an  emulsion  which  is  digestible  and  supposed  to  be  rich  in 
albumin  is  doul)tless  better  than  pure  water  or  a  thin  starch  paste.  In 
order  to  add  food  salts,  which  are  not  supplied  by  this  means,  he  extracted 
them  from  leaf  vegetables,  which  are  rich  in  food  salts,  and  added  some 
sugar  syrup.  In  this  manner  he  claims  to  have  made  a  preparation  which 
he  states  is  chemically  equal  to  human  milk,  and  full  of  nutritive  value.    His 


CONDENSED  MILK— CONDENSED  CREAM.  17 9 

idea  is  that  the  interposition  .of  plant-albumin  (conglutin)  particles,  which 
coagulate  with  difficulty  between  the  coagulating  casein  masses,  would  in- 
crease their  digestibility  by  breaking  them  up,  and  that  the  digestion  of  the 
plant-albumin  and  oil,  as  well  as  of  the  sugar  and  food  salts,  would  present 
no  difficulty. 

Stutzer,  of  the  University  of  Bonn,  reports  thus:  The  vegetable  milk 
is  distinguished  from  children's  food  by  the  absence  of  starchy  substances. 
In  common  with  Biedert's  cream  mixture,  the  vegetable  milk  contains  con- 
siderable quantities  of  fat  in  an  emulsified  condition.  It  differs  from  the 
cream  mixture  in  the  way  it  is  prepared,  and  in  its  other  qualities. 

Chemical  Analysis. 

Fat   34.72  per  cent. 

Plant-casein  and  similar  nitrogenous  constituents..  12.00  per  cent. 

Sugar  and  plant-de.xtrin    31.02  per  cent. 

Salts 1.64  per  cent. 

Water 20.62  per  cent. 

My  own  personal  experience  has  been  rather  favorable  with  the  use  of 
the  vegetable  milk,  inasmuch  as  an  emulsion  of  almonds  and  nuts  was  used 
to  dilute  the  curd  of  cows'  milk.  Thus,  equal  parts  of  vegetable  milk  with 
cows'  milk  were  taken  by  an  infant  for  several  months,  and  it  was  very 
well  assimilated.  Not  only  did  the  child  gain  in  weight,  but  the  bowels  were 
in  a  fair  condition,  and  the  infant  remained  strong. 

Condensed  Milk  or  Condensed  Cream. 

Hundreds  of  infants  are  fed  with  condensed  milk.  This  has  its 
reasons : — 

1.  The  readiness  with  which  condensed  milk  is  obtained. 

2.  The  great  cheapness  of  this  article. 

3.  The  ease  with  which  the  feeding  mixture  can  be  prepared. 

Jacobi  says  that  some  manufacturers  use  pure  cows'  milk;  others  find 
it  in  accordance  with  the  health  of  their  bank  accounts  to  use  skimmed  milk. 

Quantity  of  Sugar  in  Condensed  Milk. — Milk  sold  in  our  city  for  im- 
mediate use  contains  about  12  to  15  per  cent,  of  sugar.  Milk  to  be  kept  for 
an  indefinite  time  contains  as  much  as  50  per  cent,  of  sugar.  These  varia- 
tions show  how  serious  it  is  to  use  the  same  quantity  of  condensed  milk  all 
the  time  and  from  different  sources  with  such  an  enormous  variation  in  the 
quantity  of  sugar, 

Kehrer — quoted  by  Jacobi — states,  regarding  it,  that  it  increases  the 
formation  of  lactic  acid.  Fleischman  states  that  it  gives  rise  to  thrush  and 
diarrhoea;  Daly,  that  it  fattens  them  (  ?),  but  gives  rise  to  rachitis. 

The  worst  specimens  of  rachitis  and  spinal  rickets  seen  in  my  clinic 
are  in  condensed-milk  babies.     Our  medical  literature  reports  many  cases 


180  NUTRITION. 

of  apparent  health  in  infants  fed  on  condensed  milk.  It  has  led  Des- 
sau, with  a  large  experience  with  infants,  to  mention  such  a  method,  al- 
though he  advocates  cows'  milk,  properly  modified,  for  continued  use.^ 

In  traveling,  when  good  fresh  cows'  milk  cannot  be  obtained,  then  I 
permit  the  use  of  condensed  milk,  but  for  a  few  days  or  for  a  week  only, 
as  on  the  ocean  steamer,  where  cows'  milk  cannot  be  had. 

My  experience  among  thousands  of  children  seen  in  my  Children's 
Service  at  the  German  Poliklinik  and  also  at  the  service  at  the  West-Side 
Gennan  Dispensary  during  these  last  fifteen  years  has  been  that  children 
so  fed  have  rickets;  that  they  are  predisposed  to  the  infectious  disorders; 
that  they  have  less  resistance  and  far  less  vitality,  especially  in  combating 
such  diseases  as  pneumonia  or  diphtheria;  that  they  have  tendencies  to 
hernias  and  deformities,  owing  to  the  softer  condition  of  their  muscles  and 
bones;  that  they  invariably  suffer  with  constipation,  alternating  with  diar- 
rhoea; that  their  dentition  is  delayed,  compared  with  other  methods  of 
hand  feeding.  Thus  summing  it  up,  I  cannot  approve  of  this  method  at 
all. 

Condensed  cream  will  be  lauded  by  the  mother  whose  baby  is  well,  and 
again  the  same  food  will  be  condemned  by  the  mother  of  an  infant  whose 
rickety  head,  bones,  and  muscles  are  founded  on  an  impoverished  diet  of 
condensed  milk.  We  can  account  for  the  rickety  child,  but  we  cannot 
account  for  the  healthy  one  on  the  same  food. 

The  directions  on  the  tin  of  the  Anglo-Swiss  Condensed  Milk  Com- 
pany's Milkmaid  Brand  of  condensed  milk  are,  for  new-born  infants,  add 
14  parts  of  water;  as  the  child  grows  older,  gradually  use  less  water,  but 
never  less  than  7  parts. 

On  studying  the  clinical  relationship  of  the  component  parts  of  con- 
densed milk,  it  is  very  apparent  that,  diluting  the  Eagle  brand  of  condensed 
milk  with  14  parts  of  water,  we  have  but  0.7  per  cent,  of  protein,  0.6  per 
cent,  of  fat,  and  3.5  of  sugar.  The  deficient  bone-building  and  muscle- 
forming  ingredients  account  for  the  rachitis  which  invariably  results. 


^  See  my  paper  on  infant- feeding  ( read  before  the  Society  for  Medical  Progress, 
April  11,  1896),  published  in  extenso  in  Pediatrics  for  July  15,   1896. 


CHAPTER  VI. 
PROPRIETARY  INFANT  FOODS. 

Patent  Foods. 

Theke  are  a  great  many  infant  foods  in  use  at  the  present  time.  No 
one  will  question  the  large  amount  of  foods  sold.  This  is  due  to  several 
reasons:  First,  because  the  laity  have  been  educated  to  use  them,  when 
cows'  milk  or  even  when  breast-milk,  in  rare  instances,  disagrees;  second, 
physicians  of  large  experience  advocate  the  use  of  a  great  many  patent  foods. 
When  disturbances  in  the  stomach  or  intestines  interfere  with  the  proper 
digestion  and  assimilation  of  the  proteins,  then  frequently  the  modification 
of  the  milk,  by  the  addition  of  these  foods,  yields  good  results.  In  some 
instances  where  there  is  no  appetite  we  frequently  can  stimulate  an  appetite 
by  advocating  the  temporary  use  of  these  foods. 

In  the  large  cities,  where  breast-milk  is  unobtainable  for  infants,  these 
foods  are  frequently  given. 

During  the  course  of  summer  complaint,  typhoid  fever,  or  acute  infec- 
tious diseases,  I  have  frequently  advised  the  use  of  diluted  milk  with  several 
teaspoonfuls  of  a  nutritious  food,  rich  in  barley  malt.  The  objectionable 
features  of  patent  foods  consist  in  the  ease  with  which  they  are  procured, 
and  the  careless  manner  in  which  they  are  given.  Thus,  a  large  portion  of 
the  laity  will  follow  the  directions  on  the  label  of  the  box  of  patent  food 
to  the  detriment  of  the  child.  Many  a  case  of  rickets  or  scurvy  can  be  traced 
to  ignorance  in  giving  patent  foods.  We  know,  however,  that  there  are  some 
virtues  in  these  patent  foods,  and  to  attribute  all  cases  of  rickets  or  scurvy 
to  this  one  cause  is  wrong.  Investigations  made  by  the  American  Pediatric 
Society  showed  that  a  large  number  of  children  fed  on  sterilized  milk  suf- 
fered with  scurvy.  A  great  many  facts  must  therefore  be  considered  before 
condemning  or  praismg  one  or  all  of  the  foods.  Every  physician  knows 
that  raw  milk  or  milk  warmed  to  blood  heat  possesses  anti-scorbutic 
properties.  When  a  given  commercial  food  is  added  to  raw  milk,  thoroughly 
mixed,  and  heated  to  blood  heat  or  to  a  pasteurizing  temperature,  we  still 
retain  the  virtues  of  the  milk  and  increase  its  nutritive  value  with  the  aid 
of  the  foods  selected.  Roughly  speaking,  there  are  two  kinds  of  infant  foods 
on  the  market :  (a)  Infant  foods  to  be  used  as  adjuncts  to  fresh  cows'  milk. 
(&)  Infant  foods  in  which  desiccated  cows'  milk  is  a  constituent.  ^ 

These  foods  are  commonly  known  as  dried-milk  foods,  although  in  this 
class  of  foods  milk  solids  constitute  but  from  one-eighth  to  one-fourth  the 

(181)   . 


183  •  NUTRITION. 

substance  of  the  foods,  the  balance  consisting  of  matter  derived  from 
cereals.  In  some  of  these  foods  the  starch  of  the  cereals  is  untransformed, 
and  they  may  be  termed  farinaceous  dried-milk  foods.  In  others  the  starch 
of  the  cereals  has  been  transformed  into  dextrin  and  maltose,  and  they  may 
be  termed  dried  malted  milk  foods. 

The  group  of  infant  foods  used  as  adjuncts  to  cows'  milk  are  either 
farinaceous  foods,  made  from  cereals  and  consisting  largely  of  unconverted 
starch,  or  malted  foods,  also  made  from  cereals,  but  having  the  starch 
transformed  into  soluble  maltose  and  dextrin.  As  fresh  cows'  milk  is,  with- 
out doubt,  the  best  generally  available  material  for  the  artificial  feeding 
of  infants,  the  foods  of  the  latter  class,  used  for  the  modification  of  fresh 
cows'  milk,  are  more  in  accord  with  physiological  principles  than  are  the 
dried-milk  foods. 

Of  the  large  number  of  infant  foods  that  have  been  put  on  the  market, 
it  is  my  purpose  to  describe  a  few  commonly  known  foods.  In  order  to 
judge  fairly  of  the  nutritive  value  of  an  infant  food  and  its  resemblance 
to  woman's  milk,  it  is  necessary  to  know  its  composition  after  its  preparation 
for  the  nursing-bottle  according  to  the  directions  of  its  manufacturer,  and 
the  analyses  that  accompany  the  following  descriptions  are  of  the  foods 
prepared  for  use  for  infants  six  months  of  age  as  per  directions  on  the 
packages. 

List  of  Infant  Foods. 

The  following  list  of  infant  foods  is  quite  complete,  although  there  are 
but  four  or  five  foods  that  are  used  in  any  quantity,  the  balance  having 
a  small  demand : — 

Blair's  Wheat  Food  (cereal  food;  baked  wheat). 

Hubbel's  Wheat  (cereal  food ;  baked  wheat) . 

Wampole's  Milk  Food  (composed  of  predigested  cereals,  beef,  and 
milk) . 

Wyeth's  Prepared  Food  (composed  of  malt  milk  and  cereals). 

Just's  Food   (partially  predigested  cereals.     To  be  used  with  milk). 

Malted  Milk  (malted  and  containing  dried  milk). 

Horlick's  Food  (predigested,  to  be  added  to  milk), 

Mellin's  Food  (predigested,  to  be  added  to  milk). 

Imperial  Granum  (baked  wheat) . 

ISTestle's  Food  (composed  of  cereals  partially  predigested  and  dried 
milk) . 

Jjacto-Preparata  (dried  milk). 

Lactated  Food  (farinaceous  with  milk-sugar). 

Mammala  (dried  milk  food). 

Eidge's  Food  (farinaceous). 


NESTLE'S  FOOD.  183 

Peptogenic  Milk  Powder  (to  modify  milk) . 

Pegnin  (also  used  to  modify  the  casein  of  cows'  milk). 

Zimmerman  Barley  Oat  Food  (cereal). 

Nutrico  Food  ( cereal ) . 

Lange's  Tissue  Food  (a  condensed  milk). 

Hayes's  Oat  Food  (cereal). 

Allenbury's  Milk  Food,  No.  1  (predigested;  prepared  with  water,  con- 
tains dried  milk) . 

Allenbury's  Milk  Food,  No.  2  (predigested;  prepared  with  water,  con- 
tains dried  milk), 

Allenbury's  Malted  Food,  No.  3  (partially  predigested;  prepared  with 
milk). 

Benger's  Imported  (cereal  and  not  predigested). 

Neave's  Food,  Imported  (farinaceous). 

Eskay's  Albuminized  Food. 
'Cereal  Milk. 

Carnrick's  Soluble  Food. 

Diastased  Farina. 

Coombs's  Malted  Food. 

Eobinson's  Groats. 

Eobinson's  Patent  Barley. 

Chapman's  Whole  Flour. 

Scott's  Oat  Flour. 

Milkine. 

The  published  analyses  of  woman's  milk  show  the  great  variability  of 
its  composition,  especially  as  regards  the  percentage  of  proteins  and  fats. 
The  analysis  of  woman's  milk  used  in  the  following  tables  is  by  Dr.  Luff, 
adopted  as  the  standard  by  Cheadle.  It  agrees  closely  with  Leed's  analysis, 
excepting  as  to  the  fat,  which  is  given  by  Luff  as  2.41  per  cent,  and  by 
Leeds  as  4.13  per  cent.;  the  latter  amount  seems  too  large,  as  it  exceeds 
considerably  the  published  averages  of  a  number  of  observers. 

Nestle's  Food. 

Nestle's  food  is  a  farinaceous  dried-milk  food.  According  to  the 
manufacturers,  it  is  made  of  pure  cows'  milk,  ground  wheaten  biscuit,  barley 
malt,  and  cane-sugar.    It  is  a  form  of  modified  milk. 

No  cows'  milk  is  to  be  added  to  Nestle's  food — nothing  but  water. 

Upon  examination,  maltose,  dextrin,  and  cane-sugar  will  be  found  to 
be  its  principal  ingredients,  amounting  to  about  52  per  cent,  of  the  whole. 
The  amount  of  lactose  (6.57  per  cent.)  represents  only  that  contained  in  the 
milk  used  in.  manufacture. 


For  3d  Mo, 

6th  Mo. 

9th  Mo. 

0.96% 

1.18% 

1.30% 

2.03 

2.50 

2.73 

1.76 

2.16 

2.36 

3.22 

3.96 

4.33 

2.24 

2.77 

3.03 

0.74 

0.90 

1.00 

1.42 

1.75 

1.91 

0.19 

0.24 

0.26 

87.44 

84.54 

83.08 

100.00 

100.00 

100.00 

Reaction  alkaline. 

184  NUTRITION. 

The  directions  for  preparing  Nestle's  food  for  the  nursing  bottle,  for 
infants  six  months  of  age,  are  as  follows : — 

Place. the  required  amount  of  food  in  the  saucepan  and  add  a  sufficient 
amount  of  cold  water  to  make  a  smooth,  creamy  mixture,  then  add  the  rest 
of  the  water,  and  boil  for  two  minutes. 

Tabi,e  No.  29. — Composition  of  'NestWs  Food,  When  Prepared  for  Different  Ages. 

Analysis  by  Composition  when  Prepared 

Dr.  Boyce  W.  Knight.  According  to  Label  Directions. 


Milk  sugar  . , 7.40% 

Maltose 15.60 

Dextrin 13.51 

Cane  sugar 24.77 

Starch 17.31 

Fat 5.63 

Proteins 10.92 

Mineral  matter 1.49 

Water    3.37 

100.00 


The  total  carbohydrate  content  of  this  mixture  (12.57  per  cent.)  is 
considerably  higher  than  the  carbohydrate  content  of  milk  sugar  (6.39  per 
cent.)  of  woman's  milk.  This,  however,  may  be  accounted  for  by  the  fact 
that  the  fat  content  (0.90  per  cent.)  is  equally  lower  than  the  fat  content 
of  woman's  milk  (2.41  per  cent.). 

It  is  claimed  by  the  manufacturers  that  the  value  of  the  milk  used  in 
Nestle's  food  is  not  destroyed,  as  the  condensing  is  done  in  vacuum,  at  a 
temperature  not  exceeding  130°  F. 

When  cows'  milk  disagrees  and  gastric  symptoms  such  as  fever,  vomit- 
ing, and  intestinal  catarrh  appear,  the  substitution  of  Nestle's  food  for 
several  days  will  frequently  relieve  this  condition. 

Horlick's  Malted  Milk. 

This  is  a  dried  milk  food,  said  to  be  composed  of  pure,  rich  cows' 
milk  combined  with  the  extract  of  malted  grains,  and  not  to  require  the 
addition  of  milk,  nor  any  cooking.  The  manufacturers  claim  that  by 
their  methods  and  apparatus  the  proteins  are  rendered  very  digestible 
and  do  not  form  large,  irritating  curds  in  the  stomach. 

The  directions  for  preparing  the  food  for  an  infant  six  months  old 
are  to  dissolve  3  to  4  heaping  teaspoonfuls  in  4%  to  6  ounces  of  water. 


CEREAL  MILK.  185 

Table  No.  30. 

Eorliclc's  Malted  Milk.  Woman's  Millc. 

Water 86.29  88.51 

Salts 0.55  0.34 

Proteins    2.31  2,35 

Fat  1.24  2.4] 

Carbohydrates 9.61  6.39 

This  product  is  very  neatly  soluble  in  water,  as  its  principal  con- 
stituents are  the  soluble  carbohydrates — maltose,  dextrine,  and  milk 
sugar.  The  drying  process  is  said  to  be  conducted  very  carefully  in  a 
vacuum,  and  hence  the  solubility  and  digestibility  of  the  product,  it  is 
claimed,  are  not  lessened. 

The  proteins  are  about  the  same  as  in  woman's  milk,  but  the  fat  is 
about  three-fifths  and  the  carbohydrates  are  about  five-thirds  as  much  as 
in.  woman's  milk. 

When  cows'  milk  causes  continued  constipation,  the  substitution  of 
a  bottle  containing  hot  water  8  ounces,  in  which  4  teaspoonfuls  of  malted 
milk  are  dissolved,  is  indicated.  It  acts  as  a  corrective,  as  the  maltose 
has  a  laxative  effect. 

Horlick's  Food. 

Horlick's  food  is  prepared  from  barley,  malt,  and  wheat  flour,  and  is 
designed  to  be  used  in  connection  with  cows'  milk,  as  a  modifier.  It  is  free 
from  starch  or  cane  sugar,  and  is  completely  soluble. 

When  prepared  with  milk,  as  directed,  it  brings  the  carbohydrates  in  the 
form  of  maltose  and  dextrine  to  the  proper  standard,  and  at  the  same  time 
acts  upon  the  milk  so  that  it  is  easily  digested. 

In  some  cases  food  prepared  as  above  has  a  tendency  to  constipate.  In 
Buch  cases  the  substitution  of  malted  milk  for  the  first  morning  bottle  will 
modify  such  constipation. 

This  method  of  modifying  milk  has  been  followed  for  years,  by  many 
of  the  medical  profession,  as  a  substitute  for  mother's  milk  or  as  an  alter- 
nate with  Horlick's  malted  milk. 

This  food  is  also  indicated  as  a  diet  for  dyspeptics,  fever  patients,  and 
convalescents,  as  it  is  easily  digested,  palatable,  and  free  from  some  of  the 
objectionable  features  that  pertain  to  the  use  of  milk  alone,  as  a  diet. 

Cereal  Milk. 

Cereal  milk  is  a  malted  dried-milk  food.  It  is  stated  by  its  makers  to 
De  a  complete  food,  cooked  and  ready  for  use  with  the  simple  addition  of 


186  NUTRITION. 

water,  and  to  be  made  from,  the  purest  Vermont  dairy  milk,  the  finest 
wheat  gluten  flour,  the  best  barley  malt,  and  milk-sugar. 

Cereal  milk  in  general  appearance  very  much  resembles  the  other 
malted  dried  milk  foods,  but  it  contains  a  much  greater  percentage  of  milk- 
sugar,  showing  that  this  substance  is  used  in  its  manufacture,  as  claimed. 

The  directions  for  preparing  it  for  use  are  to  mix  1  teaspoonful  of 
cereal  milk  in  a  teacupful  of  hot  water  for  infants  under  three  months  of 
age  or  for  a  very  delicate  child. 

Preparation  for  a  child  six  months  old : — 

"To  make  6  ounces  Prepared  Food,  use  3%  rounding  teaspoonfuls  Cereal  Milk 
Powder,"  as  directed. 

Composition  when  prepared : — 

Table*  No.  31. 

Cereal  Milk.  Woman's  Milk. 

Water    90.98  86.73 

Total   solids    9.02  13.26 

Fats    0.38  4.13 

.      Proteins ^ 1.09  2.00 

Inorganic  salts   0.21  0.20 

Carbohydrates     7.34  6.93 

The  reaction  to  litmus  was  neutral,  or  faintly  acid.  The  food  contains 
starch.  No  white  of  egg  or  cream  was  added,  since  neither  is  definitely  pre- 
scribed. This  fact  may  be  taken  into  consideration  when  comparing  the 
analysis  with  that  of  the  other  foods. 

The  total  of  soluble  carbohydrates  as  above  is  practically  the  same  as 
in  woman's  milk;  the  amount  of  proteins  is  less  than  one-half  the  amount 
in  woman's  milk,  and  about  one-half  is  insoluble  in  water.  The  amount  of 
fat  is  one-eleventh  the  amount  in  woman's  milk.  The  small  amount  of  fat 
indicates  that  the  cereal  extractives  and  milk-sugar  make  up  the  bulk  of  the 
solids  of  this  food,  and  that  a  dilution  of  1  part  of  good  cows'  milk  with  11 
parts  of  water  would  be  the  counterpart  of  the  above  mixture  as  to  the 
amount  of  milk  therein. 

Wampole's  Milk  Food, 

Wampole's  milk  food  is  a  malted  dried  milk  food.  Its  makers 
state  that  it  is  made  from  malted  cereals,  beef,  and  milk,  and  when  mixed 
with  warm  water  it  is  immediately  ready  for  use;  no  other  preparation 
necessary. 

This  dried  milk  food  is  very  nearly  soluble  in  water,  owing  to  the  solu- 
ble carbohydrates  being  so  large  a  constituent.  A  little  less  than  one-half 
of  the  proteins  is  insoluble  in  water.  A  small  amount  of  beef  extract  has 
been  combined  with  the  cereal  extractives  and  dried  milk. 


IMPERIAL  GRANUM.  187 

To  prepare  it  for  an  infant  6  months  to  1  year  of  age,  the  directions 
are  to  dissolve  4  to  6  teaspoonfuls  of  the  food  in  6  ounces  of  hot  water.  Com- 
position when  prepared  by  dissolving  6  teaspoonfuls  in  G  ounces  of  water : — 

Table  No.  32. 

Wampole's  Milk-food.  Woman's  Milk. 

Water  88.59  88.51 

Salts    0.46  0.34 

Proteins   1.58  2.35 

Fat    0.73  2.41 

Maltose,  dextrin,   etc 7.65 

Milk-sugar 0.99  6.39 

Reaction  alkaline.  Reaction  alkaline. 

Compared  with  woman's  milk,  it  is  seen  that  the  carbohydrates  are 
considerably  in  excess,  and  the  proteins  and  fat  are  deficient,  the  fat  espe- 
cially, it  being  less  than  one-third  the  amount  in  woman's  milk. 

One  part  of  good  cows'  milk  diluted  with  about  3i/2  parts  of  water 
would  be  analogous  to  the  dilution  of  milk  in  Wampole's  milk  food  pre- 
pared as  above. 

Imperial  Granum, 

Imperial  granum  is  a  farinaceous  food  to  be  used  as  an  adjunct  to  cows' 
milk. 

Its  makers  state  that  it  is  a  solid  extract  derived  from  very  superior 
growths  of  wheat,  nothing  more.  It  appears  to  be  made  as  claimed  from 
wheaten  flour  and  to  be  mainly  composed  of  torrefied  starch. 

For  an  infant  six  months  of  age  it  is  to  be  prepared  by  cooking  3I/2 
teaspoonfuls  of  food  in  21  ounces  of  water  and  20  ounces  of  milk. 

Composition  when  prepared  as  above : — 

Table  No.  33. 

Imperial  G-ranum.^  Woman's  Milk. 

Water     9L53  88.51 

Salts    0.34  0.34 

Proteins    2.15  2.35 

Fat    1.54  2.41 

■    Starch    1.22 

Maltose,  dextrin,  etc •.      0.58 

Milk-sugar 2.71  6.39 

Reaction   alkaline.  Reaction  alkaline. 

The  total  of  solids  contained  is  one-quarter  less  than  in  woman's  milk; 
the  carbohydrates  are  nearly  one-third  less  than  the  amount  in  woman's 
milk,  and  it  should  be  observed  that  1.22  per  cent.,  or  about  one-fourth  of 
them,  consist  of  starch;  there  is  only  a  slight  deficiency  in  the  amount  of 


^According  to  Chittenden. 


188  NUTRITION. 

proteins,  but  a  considerable  deficiency  in  the  amount  of  fat.  By  using  more 
milk  or  milk  and  cream  and  less  water  than  above  employed  the  percentages 
of  fat,  proteins,  and  soluble  carbohydrates  would  be  increased. 

Its  very  large  proportion  of  starch  forms  the  principal  objection  to  this 
food. 

The  presence  of  unconverted  starch  causes  the  thick  condition  of  the 
mixture. 

Eskay's  Albumenized  Food.^ 

This  food  is  to  be  prepared  with  cows'  milk.  Its  makers  state,  in  rec- 
ommending their  product,  that  it  contains  the  more  easily  digested  cereals, 
combined  with  egg  albumin. 

Eskay's  albumenized  food  consists  largely  (about  88  per  cent.)  of  car- 
bohydrates; the  soluble  carbohydrates,  mostly  milk-sugar,  are  about  50  per 
cent.,  and  the  insoluble  carbohydrates,  mostly  starch,  are  a  little  less  than 
40  per  cent.  On  account  of  this  proportion  of  starchy  matter  in  the  dry 
food,  it  may  be  termed  farinaceous.  The  makers,  however,  claim  that  in 
the  process  of  manufacture  the  starch  granules  are  almost  entirely  disin- 
tegrated, and  when  the  food  is  prepared  with  milk  according  to  directions 
the  percentage  is  said  to  be  not  over  11/2  to  2  per  cent.  An  analysis  of  the 
dry  food  shows  that  it  contains  about  9  per  cent,  of  proteid  matter,  but 
when  prepared  according  to  the  six  months'  formula  it  analyzes  about  2.55 
per  cent. 

The  fats  as  well  as  the  proteins  are  almost  entirely  vegetable,  with  a 
small  percentage  of  each  derived  from  'eggs.  Excepting  the  egg,  fat,  and 
albumin,  the  preparation  is  produced  from  wheat,  oats,  and  barley,  and,  while 
no  proteolytic  ferments  are  used  in  its  manufacture,  the  insoluble  carbo- 
hydrates are'  nevertheless  partially  converted  into  dextrin  by  a  special 
process  of  heating,  which  ruptures  the  starch  granules  and  converts  a  small 
amount  of  the  starch. 

The  egg  albumin  is  said  to  be  first  combined  with  sugar  of  milk  in 
such  a  thorough  manner  that  the  particles  are  finely  subdivided,  and  no 
firm,  hard  coagulum  can  therefore  take  place  in  the  stomach.  The  particles 
retain  their  identity,  and  do  not  coalesce;  so  that  in  the  finished  prepara- 
tion the  egg  albumin  is  suspended  throughout  the  whole  mixture  in  very 
fine  particles,  which  are  easily  digested,  because  the  gastric  juice  acts  by 
contact,  and,  the  smaller  the  particles,  the  greater  the  effect  of  the  gastric 
juice.  No  claims  are  made  by  the  manufacturers  for  its  solubility,  but  for 
its  ease  of  digestion  and  its  nutritive  value. 


^  The  chemical  analyses  of  Eskay's  food,  Mellin's  food,  cereal  milk,  and  malted 
milk  here  given  were  specially  made  for  me  by  Professor  Lafayette  B.  Mendel,  at  the 
Sheffield  Laboratory  of  Physiological  Chemistry,  Yale  University. 


MELLIN'S  FOOD.  189 

Tlie  directions  for  preparing  it  for  an  infant  six  months  of  age  are  to 
take : — 

Eskay's   food    5  tablespoonfuls 

Hot  water 1  pint 

Rich  cows'  milk  2  pints 

As  directed. 

Composition  when  prepared  as  above : — 

Table  No.  34. 

Eslcay's  Food.  Woman's  Milk. 

Water   84.46  86.73 

Total  solids   15.54  13.20 

Fats    3.07  4.13 

Proteins   2.78  2.00 

Inorganic  salts   0.58  0.20 

Carbohydrates    9.11  6.93 

The  reaction  to  litmus  was  amphoteric. 

The  food  contains  a  noticeable  quantity  of  starch,  which  is  in  the  form 
of  a  thin  paste,  in  which  all  the  grains  are  ruptured  by  the  process  of  prepa- 
ration. The  boiling  was  carried  on  for  fifteen  minutes  in  the  sample  an- 
alyzed. 

Kich  milk  (4.85  per  cent,  of  fat)  was  used  as  specifically  directed. 

Mellin's  Food. 

Mellin's  food  is  a  malted  cereal.  This  food  is  stated  by  its  makers  to 
be  a  soluble  dry  extract  from  wheat  and  malt,  for  the  modification  of  fresh 
cows'  milk. 

Analysis. 

Fat  .16 

Proteins -  10.35 

Maltose 58.88 

Dextrins   20.69 

Soluble  carbohydrates   79.57 

Salts    4.30 

Water    5.62 

100.00 

The  salts,  4.30  parts,  consist  of: — 

Bicarbonate  potassium  2.536 

Phosphate  potassium 897 

Phosphate  calcium    037 

Phosphate  magnesium   213 

Phosphate  iron    016 

Chloride  sodium    097 

Sulphate  sodium    131 

Sulphate  potassium    383 

4.310 


190  NUTRITION. 

The  carbohydrates  therein  are  in  the  form  of  dextrin  and  maltose,  and 
constitute  about  80  per  cent,  of  the  food;  the  proteins  amount  to  about 
10  per  cent,  and  are  derived  from  the  cereals.  Mellin's  food  is  almost  com- 
pletely soluble  in  water.  It  is  especially  noticeable  that  this  food  does  not 
contain  any  starch. 

Whole  Milk  Formula  for  Normal  Infant,  Six  Months  Old  or  Over. 

Mellin's  food   3  %  level  tablespoon! uls 

Milk  12  ounces 

Water 4  ounces 

Analysis  of  Above  Mixture: 

Fat  2.67 

^    ,  .      r  milk 2.52 

Proteins-^           ,  .„  „  „, 

(cereal    49  3.01 

Carbohydrates   (no  starch)    7.12 

Salts .71 

Water 86.49 

100.00 
Calories  per  fluidounce 21 

The  reaction  to  litmus  was  amphoteric.  The  food  gave  no  reaction  for 
starch.    Milk  having  4.25  per  cent,  of  fat  was  used  in  this  preparation. 

In  total  solids  this  food  differs  but  slightly  from  woman's  milk,  and  in 
the  various  constituents  its  similitude  to  woman's  milk  is  remarkably  close. 
Of  the  carbohydrates  the  maltose  and  dextrin  are  a  little  less  in  amount 
than  the  milk  sugar,  and  the  total  carbohydrates  (7.12  per  cent.)  are  greater 
than  the  amount  in  woman's  milk. 

One  level  tablespoonful  of  Mellin's  food  added  to  a  16-ounce  mixture 
increases  the  percentage  of 

Proteins   0.14  per  cent. 

Carbohydrates 1.10  per  cent. 

Salts 0.06  per  cent. 

Mammala. 

Mammala  is  claimed  to  be  a  milk  from  which  a  part  of  the  cream  has 
been  removed,  an  additional  proportion  of  milk  sugar  added,  and  then  dried 
by  the  Hatmaker  process,  at  a  temperature  of  280°  F. 

It  is  a  white  powder  to  be  dissolved  in  hot  water  with  no  addition  of 
sugar  or  lime  water.  It  is  a  simple  formula  and  one  adapted  for  substitute 
feeding. 

The  absence  of  a  live  factor  such  as  an  enzyme  would  contraindicate 
the  use  of  such  food  for  a  prolonged  period.  We  must  always  bear  in  mind 
the  possibility  of  the  development  of  scurvy  where  an  absence  of  fresh  milk 
exists. 


BENGER'S  FOOD.  191 

Just's  Food. 

Maltose,  free   12.6  parts 

Maltose,  combined  with  dextrin  as  maltodextrin 15.5  parts 

Dextrin,  with  trace  soluble  starch   61.3  parts 

Albuminoids   1.1  parts 

Fat   0.1  part 

Ash    0.9  part 

Water   5.3  parts 

Cellulose 0.2  part 

Indeterminable    (insoluble)    3.0  parts 

100.0  parts 

This  sample  was  neutral  in  reaction;  the  sample  was  analyzed  June 
14,  1895;  was  slightly  acid,  which  suggests  that  the  process  of  manufac- 
ture has  been  changed  a  little.    The  food  has  no  diastasic  action. 

The  small  amount  of  albuminoids,  light  color  of  the  food,  and  the  low 
degree  of  conversion,  particularly  of  the  last  sample  analyzed,  indicate  very 
conclusively  that  no  considerable  quantity  of  malt  or  any  entire  cereal  is 
used  in  its  manufacture.  It  is  not  hygroscopic — it  can  be  exposed  to  air 
for  quite  a  long  time  without  becoming  sticky. 

Upon  examination,  the  above  analysis  indicates  a  close  relation  of  Just's 
Food  to  commercial  glucose,  although  it  contains  no  dextrose. 

A  product  similar  to  Just's  might  be  obtained  from  the  glucose  process 
if  the  process  were  stopped  early  in  the  conversion  before  the  starch  was 
converted  to  glucose;  that  is,  when  the  conversion  of  the  starch  has  pro- 
gressed only  as  far  as  dextrin  and  maltose;  or  it  might  be  possible,  during 
the  process  of  making  glucose,  to  draw  off  a  portion  in  the  earlier  stages 
of  the  process,  and  neutralize  and  clarify,  and  obtain  a  product  similar  to 
Just's  food. 

In  order  to  get  such  a  percentage,  as  is  given  in  the  analysis  of  dextrin 
and  maltose,  from  a  starch  material  by  the  action  of  malt  diastase,  it  would 
be  necessary  to  use  so  much  malt  that  the  amount  of  albuminoids  contained 
would  be  much  larger  than  is  shown  by  the  analysis,  and  the  product  would 
have  a  decided  malt  flavor  and  quite  a  marked  color,  and  these  Just's  food 
has  not. 

Benger's  Food. 

Benger's  food  contains  ferments  which  convert  the  proteins  and  starch 
during  the  preparation.  It  consists  of  cooked  wheaten  meal,  to  which  is 
added  the  natural  digestive  ferment  of  the  pancreas. 

*  Analysis  by  Chambers  Watson. 

Water   11.2 

Protein    10.4 

Fat 1.1 

C  Soluble    0.9 

Carbohydrates      j    Starch 66.3 

(  Ash 9.9 


192  NUTRITION. 

The  preparation  recommended  is  as  follows : — 

Mix  2  tablespoonfuls  (about  an  ounce)  of  food  and  4  tablespoonfuls  of 
cold  milk,  then  add  8  ounces  of  boiling  milk  and  water ;  set  aside  in  a  warm 
place  for  fifteen  minutes,  then  bring  to  the  boil. 

When  mixed  with  warm  milk  as  recommended,  the  carbohydrates  are 
nearly  all  converted  into  soluble  dextrin  and  sugar,  and  the  proteins  are 
also  partially  peptonized.  This  form  of  food  is  adapted  for  marasmic  and 
atrophic  infants  where  a  predigested  food  is  indicated  temporarily. 

Peptooenic  Milk  Powder. 

This  product  is  stated  by  its  makers  to  be  an  article  containing  milk 
sugar  and  a  digestive  ferment  capable  of  acting  on  casein,  offered  for  the 
preparation  of  an  artificial  infant  food.  McGill  states:  "It  is  not,  in  the 
strict  sense,  a  food.  Its  professed  object  is  so  to  change  the  composition 
of  cows'  milk  as  to  render  this  comparable  to  human  milk.  This  it  seeks 
to  do  by  introducing  milk  sugar  and  small  quantities  of  albuminoids."  Ac- 
cording to  McGill's  analysis,  it  is  composed  almost  entirely  of  milk  sugar 
(96.6  per  cent.). 

The  following  analysis  is  by  Leeds,  and  is  taken  from  a  circular  of  the 
makers. 

Composition  of  "humanized  milk''  prepared  as  directed,  using  4  meas- 
ures of  peptogenic  milk  powder  with  %  pint  of  milk,  I/2  pint  of  water, 
and  4  tablespoonfuls  of  cream : — 

Table  No.  35. 

Humanized  Milh.  Woman^s  Milk. 

Water 86.20  88.51 

Ash    0.30  0.34 

Proteins . . 2.00  2.35 

Fat 4.50  2.41 

Milk-sugar   7.00  6.39 

Reaction  alkaline.  Reaction  alkaline. 

Chittenden's  analysis  of  this  "humanized  milk"  is  almost  identical  with 
the  above. 

The  proteins  of  the  cows'  milk  undergo  a  change  in  the  peptonizing 
process,  being  converted  chiefly  into  partial  peptones,  and  in  this  form  they 
cannot  be  said  to  resemble  the  proteins  of  woman's  milk,  which  have  not 
been  acted  upon  by  a  proteolytic  ferment. 

The  prolonged  use  of  peptogenic  powder  may  do  harm.  It  should  be 
used  as  a  corrective  for  several  weeks  and  gradually  be  replaced  by  a  higher 
protein  content.  Excessive  carbohydrate  feeding  will  do  harm;  this  caution 
applies  as  well  to  peptogenic  powder. 


PEPTOGENIC  MILK  POWDER. 


193 


Table  No.  36. — Summary  Chiving  Comparison  of  the  Foods  Analyzed  by 
Professor  Mendel. 


Cereal  Milk. 

Malted  Milk. 

Mellin'B  Milk. 

Eskay's  Milk. 

Human  Milk. 

Water    

Total   solids    

90.98 
9.02 

90.74 
9.26 

85.37 
14.63 

84.86 
15.54 

86.73 
13.26 

Fats   

Proteins    

Inorganic  salts.. 
Carbohydrates    . 

0.38 
1.09 
0.21 
7.34 

0.63 
1.65 
0.36 
6.62 

3.16 
3.03 
0.70 

7.74 

3.07 
2.78 
0.58 
9.11 

4.13 
2.00 
0.20 
6.93 

Reaction  to  litmus 

neutral 

alkaline 

amphoteric 

amphoteric 

(The  figures  indicate  percentages  by  weight.) 


The  figures  quoted  for  human  milk  are  well-known  averages;  it  would 
be  more  accurate  to  give  figures  indicating  the  healthy  variations. 


CHAPTEE  YII. 
COXCEXTPvATED  PREPAEATIOXS  OF  ALBUMIN. 

Amoxg  the  concentrated  preparations  of  allnimin  on  the  market  are: — 

SO^IATOSE. 

Somatose,  meat  albumin,  isolated  artificially^  by  chemical  process.  A 
remed}-  which  has  more  the  character  of  a  ^Dharmaceutical  ]3reparation  of 
a  stimnlant  tonic,  ratlier  than  of  a  food.  This  is  evident  also  in  its  cost. 
It  is  used  extensiveh'  and  with  good  results.  It  is  advisable  to  be  cautious 
with  the  same  owing  to  the  diarrhceal  tendency.  It  should,  therefore,  not 
be  given  to  very  young  infants. 

Chemical  analysis : — 

Water    11.41  parts 

Digestible  albumin    41.21  parts 

Peptone    27.12  parts 

Otlier  nitrogenous  substances  estimated  by  difference 
and   assumed   to    consist    of    meat   basis    and    ex- 

tractiA'es     14.51  parts 

Ash    5.75  parts 

100.00  parts 

Somatose  is  stated  to  be  prepared  from  meat.  It  is  a  light-}' ellow  pow- 
der, odorless,  nearly  tasteless,  and  readily  and  completely  soluble  in  water. 
The  solution  has  a  slightly  alkaline  reaction. 

The  substance  is  a  predigested,  nitrogenous  food. 

It  is  probably  made  from  animal  substances,  but  we  are  unable  to 
state  from  what  materials  or  by  what  process  the  article  is  manufactured. 
Its  contents  of  phosphoric  acid  and  potassium  are  very  much  less  than 
should  be  the  case  if  it  were  prepared  from  muscular  tissue,  or  meat  in  the 
usual  sense  of  the  term. 

EUCASIX. 

Eucasin  is  an  ammoniated  salt  of  casein.  A  soluble  preparation  of 
casein,  obtained  by  chemical  process.  It  contains  phosphorus,  0.8  and  13.1 
per  cent,  of  nitrogen.  It  is  well  tolerated  by  older  children,  but  does  not 
prove  very  satisfactory  in  very  young  infants. 

Ntttrol. 
Nutrol  is  the  sodium  compound  of  casein;  also  soluble. 
(194) 


AIJU'.MIN'orS    FOODS.  195 


TRoroisr. 


Tropon  is  a  mixture  of  animal  and  vegetable  albumin.  Obtained  chiefly 
from  but'kwlieat  flour  by  dipsolvinp:  with  dilute  caustic  soda,  precipitating 
with  acid,  and  purifying  witli  liydrogvii  ])eroxide.  It  was  introduced  by 
Tinkler  {Berlin,  kiln.  ^Yo(■h(^n.,  1897,  Nos.  30,  33).  Also  sano-tropon, 
which  is  real]\-  n  luixture  of  dextrinized  barley  flour  with  tropon.  Sana- 
togen  is  verv  similar  to  tlu'  latter  preparation,  and  consists  of  casein  with 
glycero-phosphate  of  sodium,  and  13  per  cent,  nitrogen. 

Plasmon". 

Plasmon  is  a  preparation  of  casein,  partly  soluble.  Obtained  by  chem- 
ical process,  the  use  of  carbonic  acid  and  Incarbonate  of  soda.  It  is  adapted 
for  the  strengthening  of  ordinary  In'oths,  but  it  must  be  distinctly  remem- 
bered that  all  of  these  preparations  are  merely  suggestions  as  "substitutes," 
and  should  never  be  thought  of  as  suitable  for  constant  feeding. 

SOSON. 

Soson  is  a  new  albuminous  product  resembling  plasmon  and  tropon 
in  nutritive  qualities. 

Other  foods  are  Sanose-Albiimose  {Scliering) ;  also  Sanatogen.,  Eu- 
lactol,  Protogen  (Blum),  and  the  Somatose  Cream  Mixture  of  the  Elher- 
feld  Farhenwerhe. 

All  of  the  above  preparations  have  been  used  by  the  author  in  doses  of 
%  teaspoonful  added  to  either  barley  soup,  chicken  broth,  farina,  or  rice 
gruel. 

When  typhoid  fever  and  such  disorders  tax  the  ability  of  the  attend- 
ing physician,  owing  to  the  rejection  of  food,  then,  and  then  only,  should 
milk  or  its  dilution  be  laid  aside  and  the  above  foods  given  a  trial.  Valu- 
able service  has  been  frequently  given  by  such  standard  preparations  as 
panopepton,  liquid  peptonoids,  and  jMosquera's  beef  jelly  where  the  gastric 
irritability  prevents  the  regular  administration  of  milk. 

Mosqueea's  Beef  Meal. 

This  is  a  partially  digested  beef  preparation,  containing  in  addition 
to  the  proteins  13.06  per  cent,  of  fat. 
The  analysis  is : — 

Water    6.68 

Salts  and  inorganic  substances    4:.20 

Fats    , 13.01) 

Insoluble  proteins    47.01 

Albumose 29.43 


196  NUTRITION. 

Taking  the  insoluble  proteins,  albumope  and  fats,  together,  100  grams 
are  equal  to  435  calories,  while  the  albumose  alone  represents  122  calories. 


MosQUERA^s  Beef  Jelly. 

This  beef  jelly  contains  12.66  per  cent,  of  albumose  and  14.35  per  cent, 
meat  extractives.  It  represents  therefore  the  stimulant  as  well  as  the  nu- 
trient qualities  of  beef. 

A  two-ounce  jar  is  equal  to  34  calories  from  the  albumose,  and  if  we 
were  to  take  the  meat  extractives  at  the  same  ratio  the  total  number  of 
calories  would  be  94. 

Panopeptojst. 

Panopepton  represents  the  products  of  the  peptic  digestion  of  fresh, 
lean  beef,  and  of  the  proteolytic  and  amylolytic  digestion  of  whole  wheat; 
proteins  in  the  form  of  albumose  and  peptone,  carbohydrates  as  achroo- 
dextrins  and  maltose,  and  the  natively  associated  soluble,  savory,  and 
stimulant  mineral  constituents.  These  soluble  food  constituents  are  ster- 
ilized, concentrated,  and,  after  being  duly  proportioned,  are  redissolved  in 
sherry  wine. 

Panopepton  contains  20  per  cent,  of  solids  as  follows :- — 

Soluble  proteins 6  per  cent. 

Carbohydrates 13  per  cent. 

Ash 1  per  cent. 

It  will  be  noted  that  the  ratio  of  proteids  and  carbohydrates  is  as  1  to 
2.16,  which  is  best  calculated  for  a  proper  nutritive  balance.  Harrington-'s 
analysis  shows  that  it  yields  17.99  per  cent,  of  solid  matter  (including  0.97 
per  cent,  of  mineral  matter)  and  18.95  per  cent,  by  volume  of  alcohol. 

This  is  undoubtedly  one  of  the  best  predigested  foods  of  the  class  that 
contains  both  proteins  and  carbohydrates  in  their  most  available  forms,  and, 
from  the  data  supplied  by  its  manufacturers,  it  is  evident  that  it  is  designed 
upon  scientific  principles  to  represent  the  varied  constituents  of  a  mixed 
diet,  and  that  its  preparation  is  carried  out  in  a  most  perfect  manner  in  all 
respects.  The  wine  serves  both  as  a  stimulant  and  preservative,  and  the 
product  has  an  agreeable  taste  and  flavor.  One  hundred  grams  (about  3V3 
ounces)  equal  77.5  calories. 

It  must  not  be  taken  for  granted  that  because  one  chemist  finds  a  very 
high  percentage  of  alcohol  in  a  standard  preparation  the  same  amount 
will  be  found  by  other  chemists;  for  instance,  the  preparation  of  "liquid 
peptonoids,"  made  by  the  Arlington  Chemical  Co.,  was  sent  to  Dr.  Ernst  J. 
Lederle.    This  chemist  found  17.59  per  cent,  alcohol  by  volume. 


ALBUMINOUS  FOODS.  197 

Table  No.  37.- — Chemical  Analyses  hy  Dr.  Ernst  J.  Lederle  and 
J.  A.  Deghuee,  Ph.D. 

An  interesting  comparison  as  to  the  alcohol  content  can  be  made  by  studying 
the  analyses  of  the  six  nutritive  tonics  submitted  for  examination;  they  are:  — 

Nutritive  Liquid  Peptone 23.49  per  cent,  alcohol  by  volume 

(Parke,  Davis  &  Co.) 
Liquid  Peptonoids    17.59  per  cent,  alcohol  by  volume 

(Arlington  Clicmical  Co.) 
Mulford's  Pre-Digested  Beef.  .  . .    19.39  per  cent,  alcohol  by  volume 

(H.  K.  Mulford  &  Co.) 
Tonic  Beef   17.04  per  cent,  alcohol  by  volume 

(Sharp  &  Dohme) 
Trophonine    18.98  per  cent,  alcohol  by  volume 

(Reed  &  Carnrick) 
Panopepton   20.05  per  cent,  alcohol  by  volume 

(Fairchild  Bros.  &  Foster) 


CHAPTER  VIII. 

ADDITIONAL  NUTRIENTS  AND  STIMULANTS. 

Meigs's  Food. 

Meig^s  food  consists  of  milk,  cream,  sugar,  gelatine,  and  arrowroot, 
and  is  prepared  as  follows :  Of  Eussian  gelatine  or  isinglass,  20  grains,  or  a 
piece  about  two  inches  square,  is  soaked  for  a  few  minutes  in  cold  water, 
and  then  boiled  in  half  a  pint  of  water  for  fifteen  minutes,  or  until  com- 
pletely dissolved.  One  teaspoonful  of  arrowroot  is  mixed  to  a  paste  with 
cold  water,  and  then  added  to  water  to  make  half  a  pint.  This  is  now  added 
to  the  gelatine  solution,  as  is  also,  with  constant  stirring,  the  desired  quan- 
tity of  milk;  just  before  removing  from  the  fire  the  cream  is  added.  The 
amount  of  milk  and  cream  used  should  vary  with  the  age  of  the  infant. 
For  an  infant  under  one  month,  4  ounces  of  milk  and  1%  ounces  of  cream 
are  to  be  used;  for  those  older  the  milk  is  gradually  increased  to  16  ounces 
and  the  cream  to  3  ounces.^ 

ZOOLAK. 

The  subjoined  analysis  of  Dr-.  Dadirrian's  zoolak  was  made  by  Edgar 
E.  Wright,  of  Brooklyn,  N.  Y. 

In  every  100  parts  of  zoolak  there  are : — 

Water    ' 87.69 

Protein  substances '3.98 

Fat  4.91 

Milk  sugar , 2.03 

Alcohol   0.07 

Ash  or  mineral  salts 0.78 

Lactic  acid   0.50 

Carbon  dioxide  0.04 

This  analysis  shows  that  in  the  production  of  zoolak  but  little  change 
is  wrought  in  the  percentage  composition  of  the  original  cows'  milk,  save 
what  would  naturally  he  prodiiced  by  the  fermenting  and  peptonizing  actions 
of  the  kefir  ferment. 

These  fermentative  changes — primary  and  secondary — consist  in: — 

1.  The  transmutation  of  a  portion  of  the  natural  milk  sugar  into 
alcohol,  lactic  acid,  and  carbon  dioxide. 

2.  The  transmutation  of  a  certain  percentage  of  the  protein  sub- 
stances into  proteoses,  and  finally,  perhaps,  into  time  diffusible  peptones. 

^ Meigs  and  Pepper:     "Diseases  of  Children,"  1887. 
(198) 


LECITHIN.  199 

This  latter  action,  however,  does  not  change  the  percentage  presence  of  the 
protein  bodies,  as  related  to  the  total  quantity  of  milk,  but  simply  changes 
their  chemical  form. 

Owing  to  the  instability  of  the  Bulgarian  bacillus  in  diy  or  tablet  form, 
it  is  advisable  to  procure  a  fresh  culture  in  liquid  form,  which  can  be  used 
as  an  antifermentative  in  gastrointestinal  colic,  and  especially  in  con- 
stipation. 

The  iSTuTKiTivE  Vali'e  of  Ecgs. 

It  is  commonly  asserted  tliat  an  eg'^  contains  as  much  food  value  as  a 
half-pound  of  meat.  This  is  not  true.  While  there  is  an  approximate 
equivalent  between  the  albuminoids  contained  in  both,  the  egg  contains  no 
carbohydrates.  Very  young  infants  do  not  digest  eggs,  and  frequently  gas- 
tric disturbances  result  from  their  use.  This  does  not  necessarily  imply 
that  the  white  of  egg  in  its  raw  state  should  never  be  used  as  an  adjunct  to 
other  forms  of  feeding,  or  as  a  temporary  food  when  milk  disagrees  or  when 
diarrhoeal  conditions,  such  as  fermentative  and  catarrhal  intestinal  dis- 
eases, prohibit  the  use  of  milk. 

Lecithin". 

Lecithin  is  a  crystal]  izable  fat  of  a  peculiar  nature  containing  nitrogen 
and  phosphorus.  It  is  unstable.  When  chemically  treated  by  neurin  and 
glycerine  phosjohoric  acid  can  be  isolated.  Lecithin  has  also  been  found  in 
the  yolk  of  egg,  in  the  egg  of  fish,  etc.  Hoppe-Seyler  isolated  this  sub- 
stance in  1870  from  its  constant  association  with  phosphorized  albumins, 
nucleo-albumin,  and  nucleo-protein.  Lecithin  is  also  found  in  the  brain 
matter. 

Free  lecithin  has  l)een  used  clinically  and  physiologically  by  Danilewski 
in  1895.  According  to  this  physiologist,  animals  fed  with  lecithin  grew 
more  rapidly  than  those  not  fed  on  this  substance.  It  is  a  reconstructive 
and  is  indicated  in  the  treatment  of  all  disorders  of  nutrition.  My  experi- 
ence with  lecithin  has  been  limited  to  racliitis,  tuberculosis,  and  cases  in 
which  atrophy  due  to  malnutrition  is  found,  such  as  result  from  pertussis. 
I  am  also  using  it  in  cases  of  sporadic  cretinism. 

A  preparation  of  lecithin  containing  one  grain  of  pure  lecithin  to  the 
drachm  is  made  by  Eairchild  Bros.  &  Foster,  of  New  York  City.  A  tea- 
spoonful  of  this  solution  given  three  times  a  day  before  meals  has  given  me 
very  good  results. 

Lecithin  of  the  Egg. — According  to  Coloumbe,  lecithin  exists  in  all 
the  tissues,  esijeeially  in  those  endowed  with  great  vitality.  From  a  thera- 
peutic point  of  view  it  is  not  toxic,  and  it  is  assimilated  as  a  whole  in 
ordinarv  doses.     Its  action  consists  in  increasino-  the  number  of  red  cor- 


200  NUTRITION. 

puscles;  in  increasing,  in  certain  cases  at  least,  hsemoglobin ;  in  increasing 
urea  and  diminishing  uric  acid,  and  in  stimulating  the  appetite.  Its  em- 
ployment is  indicated  in  anasmia,  in  all  troubles  of  nutrition,  in  wasting  dis- 
eases, and  in  neurasthenia.  It  may  be  administered  hypodermically  or  by 
the  mouth. 

Steak  Juice  or  Meat  Juice. 

The  juice  of  broiled  steak  possesses  anti-scorbutic  properties.  I  have 
referred  to  this  in  the  chapter  on  scurvy.  When  dentition  is  delayed  or 
when  the  bony  structure  is  weak,  as  in  rickets,  steak  juice  should  be  freely 
given.    It  is  best  prepared,  fresh  each  day.    For  this  purpose  a  meat  press 


Fig.  54. 

or  lemon-squeezer  is  convenient.  From  a  pound  of  lean  steak,  slightly 
broiled,  about  three  ounces  of  juice  can  be  obtained.  This  may  be  slightly 
salted  and  given  cold  or  warm,  but  not  sufficiently  heated  to  coagulate 
the  albumin. 

If  the  taste  is  objectionable,  it  may  be  given  in  milk;  two  to  three 
teaspoonfuls  added  to  eight  ounces  of  milk  will  not  be  noticed.  The 
milk  should  not  be  warmed  above  100°  F'.  before  the  addition  of  the 
steak  juice. 

For  older  children  we  can  add  the  steak  juice  to  mashed  potato, 
spinach,  or  rice.  Bread  or  toast  saturated  with  steak  juice  is  liked  by 
many  children. 

When  fresh  steak  juice  cannot  be  obtained,  then  Valentine's  meat 
juice  can  be  tried.  For  the  treatment  of  scurvy  fresh  meat  juice  must 
be  used. 

Chocolate  and  Cocoa. 

The  addition  of  cOcoa  to  milk  is  a  valuable  adjuvant.  The  flavor  of 
cocoa  will  frequently  render  the  milk  more  palatable.    Where  fat  is  needed, 


ICE-CREAM  AND  WATER-ICES.  201 

especially  in  the  ana3mic,  rachitic,  and  marasmic  child,  cocoa  is  indicated. 
High  fats  are  demanded,  for  example,  during  cough,  or  during  con- 
valescence following  influenza,  bronchitis,  or  pulmonary  lesions.  It  is  of 
especial  value  in  tuberculosis.  While  cocoa  is  looked  upon  with  disfavor  in 
the  treatment  of  intestinal  disorders,  it  will  be  found  of  advantage  in  con- 
stipation for  two  reasons:  first,  because  of  the  high  fat  content;  second, 
because  of  the  mechanical  stimulus  which  cocoa  exerts  in  exciting  peristaltic 
waves.  It  is  also  indicated  as  a  restorative  following  the  acute  infectious 
diseases  and  where  considerable  emaciation  exists. 

Cocoa  is  made  from  bitter  chocolate  by  expressing  part  of  the  cocoa 
butter  and  grinding  the  partially  defatted  material  to  a  fine  powder.  The 
amount  .of  cocoa  butter  remaining  varies  from  20  to  30  per  cent.  Cocoa  for 
drinking  purposes  has  about  25  per  cent,  cocoa  butter.  Cocoa  of  this  com- 
position has  a  calorific  value  of  about  1769  calories  per  pound,  and  contains 
approximately  19  per  cent,  protein.  A  teaspoonful  of  cocoa  powder,  required 
to  make  a  cup  of  the  beverage,  would  therefore  have  a  fuel  value  of  about 
20  calories.  Added  to  the  caloric  value  of  a  cup  of  4  per  cent,  milk, 
which  is  120  calories,  we  have  the  caloric  value  of  a  cup  of  cocoa,  which  is 
140  calories. 

Analysis  of  Hekshey^  Cocoa  Powder. 

Fat    24.12  per  cent. 

Moisture    3.57  per  cent. 

Crude    fiber    4.48  per  cent. 

Total   ash    5.17  per  cent. 

Water-soluble  asli    2.06  per  cent. 

Water-insoluble  ash 3.11  per  cent. 

Alkalinity  (soluble  of  ash)      1.85  c.c.  N/10  acid  per  gi-amme  sample, 
(insoluble)  ....     4.51  c.c.  N/10  acid  per  gramme  sample. 

Bitter  chocolate  is  the  product  obtained  by  grinding  cocoa  nibs  (roasted 
cocoa  beans) .  Such  bitter  chocolate  contains  about  52  per  cent,  of  cocoa 
butter. 

Sweet  chocolate  is  the  same  as  bitter  chocolate  with  the  addition  of 
about  50  per  cent,  of  sugar,  depending  on  the  formula.  Its  caloric  value 
is  about  2620  calories  per  pound. 

Ice-cream  and  Water-ices. 

Ice-cream  and  water-ices  are  very  grateful  to  a  feverish  child.  When 
milk  and  cream  are  refused  they  will  be  gTeedily  taken.  These  prepara- 
tions will  alleviate  the  pain  on  swallowing  in  the  case  of  diphtheria.  They 
contain  considerable  nourishment,  but  must  be  given  in  moderation.  Nau- 
sea and  vomiting  may  frequently  be  controlled  by  them. 

*  This  cocoa  is  manufactured  by  Hershey,  of  Pennsylvania. 


202  NUTRITION. 


The  Use  of  Coppee  in  Children.^ 

Contraindications. — When  giving  coffee  to  children  we  must  hear  in 
mind  that : — 

First. — Coffee  is  in  no  sense  a  food,  because  it  can  neither  build  up 
the  tissues  nor  provide  them  with  potential  energy. 

Second. — Coffee  perhaps  acts  the  part  of  a  lubricant  to  the  machinery 
of  the  body,  and  exerts  its  stimulating  influence  by  toning  up  and  dimin- 
ishing nervous  fatigue  in  adults,  and  is  not  called  for  in  children. 

Third. — Coffee  produces  a  disturbance  of  digestion  due  to  a  direct 
interference  with  the  chemical  part  of  the  process,  but  in  part  also  indi- 
rectly brought  about  by  the  nervous  system;  it  also  produces  a  dyspepsia 
which  is  of  the  atonic  type,  and  a  slow  digestion,  accompanied  by  flatu- 
lence, with  a  disturbance  of  the  heart's  action,  so  that  it  is  decidedly  con- 
traindicated  from  a  feeding  standpoint. 

Coffee  is  a  cardiac  stimulant,  quickening  the  heart's  action  in  small 
doses,  and  depressing  it  in  large  quantities. 

It  certainly  disturbs  the  cardiac  rhythm  when  taken  in  excessive  doses 
by  children.  Such  symptoms  as  muscular  tremor,  nervous  anxiety,  and 
dread  of  impending  danger,  as  well  as  palpitation;  cardiac  intermissions, 
and  an  uncomfortable  feeling  referred  to  the  cardiac  region  can  be  traced 
to  coffee,  according  to  Yeo;  it  is  a  diuretic,  and  increases  the  excretion  of 
urea;  it  produces  insomnia,  nervousness,  and  fear;  also,  choreiform  move- 
ments. 

Caffeine  has  been  known  to  produce  paralysis  in  the  lower  animals, 
and  might  produce  a  similar  effect  if  taken  in  large  quantities  by  children. 
It  retards  digestion ;  hence  it  is  contraindicated  in  children. 

Owing  to  the  great  tendency  to  produce  insomnia  coffee  should  not  be 
administered  in  the  evening  unless  the  heart's  action  demands  it. 

Indications. — As  a  cardiac  stimulant,  or  whenever  caffeine  is  indicated, 
hot  coffee  should  be  given  in  sm.all  doses,  one  or  several  teaspoonfuls,  re- 
peated every  fifteen  minutes,  until  its  physiological  effect  is  manifested. 
This  can  only  be  noted  by  studying  the  pulse.  Great  care  should  be  exer- 
cised in  administering  large  quantities  of  coffee  to  children,  or  very  strong 
coffee,  as  in  either  instance  it  will  produce  a  marked  cardiac  depression, 
and  also  a  disturbance  of  the  cardiac  rhythm. 

In  the  convalescence  of  typhoid  fever  or  pneumonia  in  children,  there 
is  no  better  stimulant  than  coffee  administered  in  small  doses  to  which 
large  quantities  of  milk  or  cream  are  added.  This  is  an  especially  valuable 
drug  in  the  great  cardiac  depression  so  frequently  noted  in  the  convales- 


^  Paper  read  by  me  before  New  York  County  Medical  Association,  December  17, 
1900,  "Acute  and  Chronic  Coflfee  Poisoning."     See  Transactions. 


ALCOHOL.  203 

cence  of  diphtheria.     (See  chapter  on  "Diphtheria.")     The  coffee  usually 
used  consists  of  the  following  strength : — 

Coffee 2  ounces 

Water  1  pint 

When  an  infusion  of  the  ahove  strength  is  made,  Hutchison  found 
that  each  teacupful  of  coffee  contained : — 

Caffeine  L7     grains ;  and  also 

Tannic  acid 3.24  grains 

The  latter  in  the  form  of  gallo-tannic  acid;  so  that  judging  from  this 
analysis,  coffee  should  be  made  much  weaker  (one  ounce  to  a  pint  of  water), 
and  should  be  administered  in  teaspoonful  doses. 

For  fuller  details  on  "Physiological  Effect  of  Coffee,"  read  paper  and 
discussion  at  the  Kew  York  County  Medical  Association,  1900,  by  Leszyn- 
sky,  Fischer,  and  others. 

The  Use  of  Alcohol  in  Children. 

Alcohol  in  the  form  of  wine  or  beer  or  whisky,  in  any  and  every  form, 
is  not  only  detrimental  to  the  infantile  organism,  but  will  leave  permanent 
injury  if  its  use  is  prolonged.  There  is  a  decided  difference  between  the 
continual  use  of  alcohol  as  a  food  and  its  use'  when  indicated  as  a  medicine. 
Physicians  know  that  whisky  or  wine,  given  to  stimulate  the  weakened  heart 
in  the  course  of  a  septic  pneumonia  or  diphtheria,  is  not  only  necessary, 
but  frequently  the  only  means  of  prolonging  life.  If  a  child  has  been  given 
alcoholic  drinks  daily  as  an  adjuvant  to  other  articles  of  food,  when  it  is 
required  to  stimulate  the  heart  we  must  resort  to  enormous  doses  to  procure 
an  effect. 

Alcohol  should  be  regarded  as  a  poison ;  therefore,  as  an  irritant  to  the 
kidneys.  The  growing  child  does  not  assimilate  alcohol.  It  interferes  with 
the  metabolism  of  fat  and  protein,  and  its  use  therefore  should  be  limited 
to  stimulating  the  heart  when  weakness  exists  during  a  septic  process. 

In  a  large  children's  clinic  with  which  I  have  been  associated  it  was 
very  interesting  to  study  the  amount  of  alcohol  given  to  young  children, 
and  I  was  surprised  to  find  that  more  than  50  per  cent,  of  all  children  from 
six  months  old  and  upward  regularly  received  their  sip  of  beer  or  drop  of 
whisky  "to  strengthen  their  hearts."  The  author  has  frequently  attended 
alcoholic  dyspepsia  due  to  prolonged  use  of  beer  and  wine.  This  is  most 
common  among  the  tenement  population,  where  the  baby  forms  part  of  the 
family  at  the  table,  and  necessarily  partakes  of  almost  everything  eatable 
and  drinkable  along  with  its  parents. 

In  the  routine  examination  it  is  the  duty  of  every  physician  to  inquire 
into  the  habit  of  giving  alcohol  to  children. 


304  NUTRITION. 


The  Use  oe  Tea  in  Childkeit. 

In  my  chapter  on  the  use  of  coffee,  I  have  already  mentioned  the 
deleterious  effect  of  coffee  on  the  growing  infant  or  child;  what  has  been 
said  there  regarding  coffee  applies  equally  strong  to  the  use  of  tea.  The 
nervous  system  when  overstimulated  in  an  infant  is  far  more  sensitive  than 
the  adult.  The  author  has  frequently  noted  that  children  suffered  with 
sleeplessness  and  were  very  irritable,  simply  through  the  prolonged  use  of 
such  stimulants  as  tea  and  coffee.  A  noteworthy  point  is  that  the  appetite 
disappears  when  tea  and  coffee  are  given,  and  reappears  when  their  use  is 
interdicted. 

It  must  not  be  supposed  that  tea  is  a  poison,  and  there  are  times  when 
physicians  will  find  it  necessary  to  use  small  quantities  of  tea  to  stimulate 
the  body,  as,  for  example,  in  that  form  of  exhaustion  following  a  protracted 
diarrhoea,  as  is  usually  the  case  in  summer  complaint,  so-called  cholera 
infantum. 


PAET  IV. 

DISEASES    OF    THE    MOUTH,    (ESOPHAGUS,    STOMACH, 

INTESTINES,     AND     RECTUM,     AND     DISEASES 

ASSOCIATED  WITH  IMPROPER  NUTRITION 


CHAPTEIi  I. 

DISEASES  OF  THE  MOUTH. 

Stomatitis. 

An  infection  existing  on  the  tonsils  or  in  the  pharynx  can  spread  to 
the  month.  Pood,  especially  milk,  is  sometimes  the  means  of  directly  con- 
veying poison ;  this  is  especially  true  when  milk  contains  pathogenic  bac- 
teria. As  I  have  frequently  stated  that  syphilis  and  rickets  undermine  the 
system,  so  also  we  find  these  conditions  frequently  as  predisposing  causes. 
The  mouth  is  particularly  liable  to  local  infection.  The  slightest  trauma- 
tism by  diseased  teeth,  especially  in  acute  cases,  can  produce  local  irritation. 
Non-pathogenic  bacteria  are  always  present  in  the  buccal  cavity  under  nor- 
mal conditions. 

"The  glands  of  the  mouth  being  excretory  frequently  produce  inflam- 
matory conditions  by  virtue  of  systemic  poison  excreted  by  them  which 
may  produce  local  lesions."  One  of  the  best  writers  on  this  subject  is 
Forchheimer,  whose  classification  I  have  adopted :  I.  Stomatitis  Catar- 
rhalis.  II,  Stomatitis  Aphthosa.  III.  Stomatitis  Mycosa.  IV.  Stomatitis 
Ulcerosa.  V.  Stomatitis  Gangrenosa.  •  VI.  Stomatitis  Crouposa;  Stoma- 
titis Diphtheritica.    VII.  Stomatitis  Syphilitica. 

Stomatitis  Catarrhalis. 

Simple  stomatitis  may  be  confined  to  a  local  area  or  it  may  be  general. 
When  the  mucous  membrane  is  irritated  by  severe  rubbing,  as  during  mouth 
cleaning,  this  condition  frequently  follows.  Dentition  does  not  produce 
stomatitis.  This  catarrhal  form  is  usually  one  of  the  earliest  manifesta- 
tions of  acute  infectious  diseases.  Great  stress  is  laid  on  this  condition 
as  a  diagnostic  point  in  measles  prior  to  or  associated  with  tlie  enautheni 
on  the  buccal  mucous  membrane.  When  a  small  area  is  affected,  a  local 
cause,  such  as  a  diseased  or  sharp  tooth,  or  some  mechanical  cause,  must  be 
looked  for. 

(205) 


206  DISEASES  OF  THE  MOUTH. 

Symptoms. — The  usual  symptoms  of  pain,  hypersemia,  and  swelling 
are  noted.  The  lining  of  the  mouth  is  puffed  and  hypersemic.  The  mucous 
membrane  is  covered  with  small,  round  prominences  due  to  the  swelling  of 
the  muciparous  follicles.  When  the  ducts  of  the  latter  become  closed  the 
glands  dilate  and  there  are  produced  cysts,  the  contents  of  which  are  clear, 
viscid  mucus.  We  also  find  slight  epithelial  abrasions,  sometimes  leading 
to  the  production  of  a  deeper  process;  at  all  events  important  in  that  they 
may  become  the  seat  of  infection.  The  lymphatics  are  usually  involved, 
and  they  serve  as  a  guide  to  the  intensity  of  the  inflammation.  Cases  are 
on  record  where  the  temperature  reached  104:°  P.  in  the  rectum,  but  these 
are  rarities. 

The  prognosis  is  invariably  good.  Unless  some  chronic  disease  is  the 
seat  of  this  trouble  there  are  rarely  any  disagreeable  after-effects. 

Treatment. — The  treatment  consists  in  cleanliness.  Eemove  the  cause 
if  possible.  Eemove  mechanical  irritants,  such  as  diseased  or  sharp-pointed 
teeth.  Boric  acid,  1  per  cent,  solution,  or  sulphocarbolate  of  zinc  or  sulpho- 
carbolate  of  soda,  1  grain  to  the  ounce,  are  valuable  local  astringents.  At 
times  nitrate  of  silver  (2  grains  to  the  ounce)  will  act  well  when  applied 
locally.  Forchheimer  recommends  the  application  of  silver  nitrate  when 
there  is  loss  of  epithelium.  Cysts  should  be  opened  and  their  walls  cau- 
terized when  necessary.  My  best  results  are  obtained  by  the  use  of  argyrol, 
5  to  10  per  cent,  solution. 

Stomatitis  Appithosa. 

This  condition  is  not  follicular  and  has  nothing  to  do  with  the  mucip- 
arous follicles,  as  it  is  found  in  places  where  there  are  none. 

It  consists  in  a  hypersemia  of  the  mucous  membrane  of  the  mouth 
associated  with  superficial  ulcers. 

Causes. — There  seems  to  be  a  decided  reason  for  believing  that  this 
disease  is  of  microbic  origin.  Aphthous  ulcerations  have  been  seen  in 
children  partaking  of  milk  from  cows  that  suffered  with  foot  and  mouth 
disease.  Demme^  reports  a  case  of  twins  fed  on  goat's  milk,  the  goat  having 
foot  and  mouth  disease.  The  milk  was  fed  fresh  and  raw.  One  of  the 
twins,  the  boy,  had  a  severe  aphthous  condition  of  the  entire  mouth  and 
throat,  and  died  after  seven  days  of  illness.  The  other,  a  girl,  was  also 
sick  with  aphthous  sore  mouth,  but  recovered  after  five  days'  illness. 

Eobinson^  reports  a  severe  epidemic  of  aphthge  acquired  from  foot 
and  mouth  disease  in  Devonshire.  Two  hundred  and  five  persons  were 
affected  in  one  week.  Two  children  died,  the  aphthous  condition  having 
extended  to  the  respiratory  tract. 


^Vienna  Medical  Journal,  vol.  vi,  1883. 
^London  Practitioner  for  1884. 


STOMATIIIS  AI'iri'lloSA. 


207 


Boas,  of  Berlin,  lias  also  reported  cases  of  foot  and  mouth  disease  and 
their  results.  Bolm  states  that  the  disease  is  most  common  between  the 
tenth  and'tliirteeiiili  iiioutlis  of  life.  Therefore,  teething  has  something  to 
do  with  the  eruption.  iSiegel  studied  an  epidemic  of  foot  and  mouth  dis- 
ease, resulting  in  aphthous  stomatitis  in  children.  An  ovoid  bacillus  0.5  /a 
long  was  found  in  all  cases.  AVe  can  assume  that  foot  and  mouth  disease 
in  cattle  is  tlie  etiological  factor  of  stomatitis  aphtliosa  in  the  human  being. 
Symptoms. — White  or  yellowisli-wliite  epitlielial  spots  are  seen  singly 
or  in  groups,  surrounded  by  an  areola   and  developing  anywhere   in  tlie 

mouth.  In  many  cases 
the}^  extend  into  the 
pharynx,  and  Forch- 
heimer  believes  into 
the  larynx.  This  dis- 
ease is  frequently  as- 
sociated with  acute 
gastric  catarrh,  consti- 
pation, and  with  gen- 
eral toxEEmic  condi- 
tions. The  eruption 
may  be  preceded  by 
pain  in  the  throat, 
fever,  enlargement  of 
the  lymphatics,  and  a 
general  train  of  nerv- 
ous symptoms  so  com- 
mon in  children. 

The  diagnosis, 
therefore,  will  be  ditfi- 
cult  until  the  erup- 
tion appears.  Tiie 
spots  frequently  are 
absorbed.     Successive  crops  may  come  and  go. 

Treatment. — The  treatment  consists  in  giving  laxatives  such  as  rhu- 
barb and  magnesia,  or  inf.  senna  comp.  The  diet  must  be  regulated.  If 
the  child  has  been  given  solids  they  should  be  excluded.  The  discontin- 
uance of  milk  is  frequently  beneficial. 

Localhj,  a  weak  solution  of  listcrine  as  an  antiseptic  can  be  used.  If 
the  child  is  old  enough  it  should  rinse  its  mouth  and  gargle  its  throat  with 
the  same.  Nitrate  of  silver,  10  grains  to  the  ounce,  or  in  some  instances 
tincture  of  chloride  of  iron,  has  served  me  very  well.  The  glycerite  of  car- 
bolic acid  ajjplied  with  absorbent  cotton  is  frequently  efficacious. 


Fig.  55.— A  Case  of  Sprae  (Thnish)  due  to  Faulty 
Hygiene  of  the  Mouth.  Note  Threads  (Mycelium)  and 
Small  Oval  Bodies  (Spores).  (After  Jagic,  Klinische  Mi- 
kroskopie.) 


208  DISEASES  OF  THE  MOUTH. 

Bednae's  Aphtha. 

The  small,  yellowish-white,  -ulcerative  patches  which  appear  on  one  or 
both  sides  of  the  hard  palate  in  the  new-born  are  known  as  Bednar's  aphthae. 
They  may  be  mistaken  for  the  nlcers  produced  by  the  breaking  down  of 
milia  or  retention  cysts,  or  for  that  condition  described  by  Epstein  in 
which  there  are  congenital  defects  in  the  mucous  membrane  filled  up  with 
epithelial  detritus  (Forchheimer).  They  are  usually  the  result  of  violence 
in  cleaning  the  mouth.  Fi'equently  an  improperly  shaped  nipple  will  cause 
this  condition  by  pressing  on  the  palate. 

Dr.  A.  Jacobi,  in  the  Archives  of  Pediatrics,  says : — 

"Do  not  be  so  fearfully  clean.  Perhaps  it  is  best  to  leave  the  infant's 
mouth  alone  with  the  exception  of  the  first  washing  with  sterilized  water 
immediately  after  birth.  Otherwise  the  mouth  should  be  cleaned  by  the 
baby's  feeding  and  by  the  practice  I  have  recommended  these  dozen  of  years 
— viz. :  to  give  a  teaspoonful  or  two  of  water  after  every  feeding.  That  will 
wash  down  all  remnants  of  food  that  might  get  decomposed  in  the  mouth. 
These  'aphtha'  will  get  well  when  left  alone;  but  as  long  as  there  is  a 
sore  surface  there  is  a  possibility  of  microbic  invasion;  for  that  reason 
alone  they  should  be  treated." 

The  affected  area  should  be  gently  wiped  with  cotton  wound  around 
the  finger,  and  dipped  into  a  saturated  solution  of  boric  acid. 

Stomatitis  Mycosa,  oe  Paeasitic  Stomatitis. 

This  disease  is  commonly  known  as  thrush,  sprue,  soor,  or  muguet. 
It  occurs  in'  the  mouth  in  the  form  of  yellowish- white  spots  and  is  due  to 
a  microbe.  A  fungus  was  first  discovered  by  Berg,  of  Stockholm,  and  called 
o'idium  albicans  by  Bobbin.  Forchheimer  states  that  the  fungus  is  found 
in  two  forms,  the  yeast  form  and  the  globulofilimentous  form  (frequently 
called  mycelium).  "There  is  no  ascospore,  therefore.  Eoux  and  Linoissier 
state  that  the  fungus  is  not  a  saccharomyces.  The  chlamydospore  has, 
however,  not  been  satisfactorily  worked  out." 

Propagation  goes  on  in  three  ways :  by  filaments  produced  from  conidia, 
by  isolated  conidia,  and  by  spores. 

Symptoms. — Local  symptoms  vary  with  the  severity  of  this  condition. 
At  times  no  symptoms  precede  the  appearance  of  these  small  spots.  The 
spots  are  grayish  white  or  creamy  in  color.  They  may  be  elevated  above 
the  surface  of  the  mucous  membrane.  They  are  not  confined  to  the  gums, 
but  appear  frequently  on  the  lips,  tonsils,  pharynx,  and  cheeks.  There  is 
a  fetid  breath  due  to  the  inflamed  gums.  Children  that  are  old  enough  to 
complain  do  not  describe  any  subjective  symptoms.  The  lymphatic  glands 
are  always  enlarged  and  do  not  suppurate.  When  suppuration  takes  place 
it  will  follow  after  the  disease  in  the  mouth  has  disappeared. 


CROLTOrS   STOMA  Til' IS.  209 

Treatment. — rro'phylactic  ireaiuicnt  of  the  mouth,  consisting  in  the 
usual  liygic'iiic  measures,  can  ])revent  this  condition.  Aseptic  details  must 
he  rigidly  enforced  in  the  nursing  l)ottles  and  nipples  when  tins  disease  is 
present. 

Treatment  consists  in  the  ajjplication  of  a  1  per  cent.  l)oric  acid  solu- 
tion as  a  mouth  cleanser,  followed  by  the  local  application  of  a  '^  per  cent, 
chlorate  of  potassium  solution.  Where  a  specific  cause  exists,  such  as 
carious  teeth  or  dead  bone,  the  same  should  be  removed  before  attempting 
to  cure  this  condition. 

CROurous  Stomatitis,  or  Diphtheritic  Sto^matitts. 

This  rare  condition  is  occasionally  met  with  in  children.  The  prog- 
nosis and  treatment  should  be  considered  just  the  same  as  though  we  were 
dealing  with  diphtheria  in  the  throat.  The  following  interesting  case  was 
sent  to  my  clinic  at  the  New  York  Post-Clraduate  Medical  School  in 
189-i:— 

The  child  was  seven  months  old,  female,  breast-fed,  had  always  been  in  good 
health.  No  family  history  of  tuberculosis,  lues,  rheumatism,  or  epilepsy.  The  child 
was  vaccinated  when  about  six  months  old,  had  had  no  previous  illness  excepting 
slight  irritability  about  the  time  of  the  eruption  of  the  first  tooth.  It  has  two 
teeth,  incisors,  lower  jaw.  General  aj^pearance  not  anaemic  or  rachitic,  has  well- 
nourished  muscles  and  a  fair  amount  of  fat.  Skin  has  a  healthy  appearance.  Four 
other  children  in  same  family;  three  apparently  healthy;  the  fourth  is  convalescing 
from  an  attack  of  "sore  mouth."  The  infant  has  been  gaining  weight  regularly  since 
birth.     It  now  weighs  15  pounds  and  8  ounces. 

An  examination  of  the  infant  showed:  Two  large  patches — one  on  the  tip  of 
the  tongvie;  the  other  on  the  soft  palate — which  were  irregular  in  outline,  yellowish- 
green  in  appearance.  Temperature  in  the  rectum  1001-^°  F.,  at  11  a.m.;  pulse,  142; 
respiration,  39.  Cervical  glands  considerably  enlarged  on  both  sides.  No  history 
of  existing  infectious  disease  in  the  same  locality.  The  diagnosis  of  stomatitis 
ulcerosa  was  made  and  a  question  mark  (?)  entered  after  the  same.  Diphtheria 
was  suspected.  The  mother  was  cautioned  in  regard  to  the  other  children,  and  the 
case  carefully  watched.  I  again  saw  the  case  two  days  later  and  found  the  child 
in  a  worse  condition.  The  temperature  in  the  rectum  at  4  p.it.  was  102if,°  F. ; 
pulse,  160;  small,  feeble,  but  quite  regular.  The  examination  of  the  mouth  showed 
an  extension  of  the  inflammatory  condition  of  the  patches,  now  involving  the  uvula 
and  left  tonsil.  The  pharynx  showed  an  abnormal  redness,  but  no  membrane  was 
visible. 

The  mother's  breast  was  painful  on  pal])ntion.  Tlio  glands  were  distended 
with  milk,  and  the  axillary  glands  enlarged  and  tender  on  palpation.  The  motlier 
complained  of  aching  in  her  limbs — a  '"tired  feeling,"  as  she  called  it — and  had 
chills,  alternating  with  fever.  Her  temperature  was  90ff,°  F.  in  the  mouth. 
There  were  membranous  patches  around  one  of  her  nipjiles.  This  resembled  a 
cracked  nipple.  While  examining  the  infant's  mouth  I  saw  what  appeared  to  be 
membrane.  A  similar  condition  was  found  around  the  nipple.  T  inoculated  two 
agar-agar  tubes  and  placed  them  in  the  thermostiit.  After  twelve  hours,  small 
colonies  of  both  streptococci  and  bacilli  could  be  seen.     On  staining  with  Loelfler's 

14 


210  DISEASES  OF  THE  MOUTH. 

alkaline  methylene  blue,  showed  distinct  semblance  to  Klebs-LoeflBler  bacilli.  A 
culture  was  made  from  the  patch  in  the  mouth,  from  the  uvula,  and  also  from  the 
pharynx.  The  tube  inoculated  with  the  uvula  patch  and  the  one  from  the  tongue 
contained,  in  almost  pure  culture,  the  characteristic  Kleb.s-Loeffler  bacilli.  The  usual 
method  of  treatment  and  active  stimulation  was  given.  Concentrated  liquid  diet 
(rectal  feeding)  was  given  when  the  infant  refused  the  breast.  An  important 
question  suggested  itself:  Shall  we  wean  the  infant?  or,  mother  and  infant  having 
the  same  disease,  could  the  infant  be  nursed  on  the  healthy  breast?  It  will  be 
remembered  that  only  one  nipple  was  diseased.  I  resolved  to  give  the  infant  the 
milk  of  the  healthy  breast  and  to  guard  against  another  sore  nipple  by  nursing 
through  a  glass  nipple  shield.  The  milk  in  the  diseased,  or  left,  breast  was  drawn 
out  with  a  breast-pump  and  thrown  away. 

Three  weeks  after  the  apparent  cure  of  the  mother's  breast  and  also  after  the 
last  visible  membrane  from  the  infant's  throat  disappeared,  the  mother  complained 
that  she  slept  with  one  eye  open.  On  examination,  I  found  a  distinct  facial  paralysis 
on  the  right  side.  The  diagnosis  was  strengthened  by  the  sequel  in  the  case.  To 
sum  up:  I  believe  the  infant,  while  having  diphtheria,  infected  its  mother  through 
the  fissure  of  the  breast  during  the  act  of  nursing.  Considering  the  physiology  of 
nursing,  we  know  the  role  played  by  the  tongue,  and,  as  the  disease  was  first  mani- 
fested thereon,  it  can  be  readily  seen  how  this  might  have  been  inoculated  from 
tongue  to  the  breast  through  its  cracked  nipple. 

Syphilitic  Stomatitis. 

Primary  infection  in  syphilis  is  by  no  means  rare.  It  usually  occurs 
by  transmission  from  a  wet-nurse  suffering  with  syphilis. 

A  case  of  this  kind  was  seen  by  me  in  an  infant  nine  months  old.  This 
infant  was  accidentally  infected  by  a  woman  who  nursed  it  during  the  mother's 
illness.  She  had  erosions  (cracked  nipples)  and  did  not  know  that  she  suffered  with 
syphilis.  Her  own  child  died  of  distinct  syphilis,  having  had  pemphigus  and  the 
general  cachexia  so  common  in  luetic  conditions.  This  case  was  given  small  doses 
of  calomel,  and  given  a  bichloride  bath  (see  chapter  on  "Syphilis")  and  showed  signs 
of  improvement  almost  immediately.  In  the  mouth  of  this  child  the  ordinary  mucous 
patches  were  found. 

Treatment  is  that  of  syphilis.     (See  chapter  on  "Syphilis.") 

Noma  (Stomatitis  Gangrenosa;  Cancrum  Oris^). 

This  disease  is  frequently  called  noma,  and  sometimes  cancrum  oris. 
It  is  characterized  by  a  gangrenous  destructive  process  located  on  the 
cheek.  Although  the  left  cheek  is  the  favorite  site  of  the  disease,  it  can 
frequently  be  found  on  both  cheeks.  The  writer  has  met  with  children 
suffering  from  this  disease  on  the  right  cheek.  Girls  are  more  liable  to 
noma  than  boys.  It  is  usually  secondary  to  some  contagious  disease,  and 
has  been  known  to  follow  typhoid  fever,  smallpox,  scarlet  fever,  measles, 
pertussis,  and  allied  infectious  disorders.  We  must,  therefore,  assume 
that  the  infectious  diseases  are  predisposing  factors  in  the  development  of 
this  disease. 


"■  Extracted  from  the  American  Journal  of  the  Medical  Sciences,  April,  1902. 


NOMA.  211 

The  process  usually  commences  on  the  gums  or  the  inner  portion  of 
the  cheek,  and  spreads  very  rapidly  to  the  adjacent  tissues.  Thus  it  is 
that  it  will  destroy  the  inner  portion  of  the  cheek  and  spread  to  the  outside, 
causing  similar  destruction  to  the  healthy  tissues. 

Bacteriolo^. — Perthes^  in  1899  found  that  noma  is  due  to  a  fungus-like 
growth  belonging  to  the  streptothrix  group.  At  the  border  line  between  the 
gangrenous  ulcer  and  nomial  tissue  he  found  a  thick,  branching  network  of 
fine,  fusiform  threads — mycelium.  From  this  mycelium  single,  fine  rods  and 
spirilla  extend  into  the  normal  tissue,  suiTound  the  cells,  and  cause  their 
death.  Krahn  believes  that  the  growth  described  by  Perthes  consists  of  two 
organisms — the  spirillum  sputigenum  and  spirochete  dentium.  The  major- 
ity of  observers  agree  with  Perthes  and  Seiffert.  The  same  bacteriological 
picture  was  described  in  noma  of  other  parts  of  the  body  by  Matzenauer. 
Perthes  prepared  his  specimens  for  examination  by  treating  the  teased  tissue 
or  section  from  the  edge  of  the  ulcer — removed  post  mortem — with  dilute 
carbol-fuchsin  for  twenty-four  hours  and  then  briefly  washing  with  alcohol. 
Weaver  and  Tunnicliff-  demonstrated  that  this  streptothrix  is  decolorized  by 
Gram's  method.  They  obtained  the  best  staining  reactions  by  dropping  a  10 
per  cent,  saturated  solution  of  alcoholic  gentian  violet  in  5  per  cent,  phenol 
on  the  section  (that  had  been  embedded  in  paraffin,  treated  with  xylol,  fol- 
lowed by  absolute  alcohol)  for  five  minutes,  clearing  with  aniline  oil,  wash- 
ing with  xylol,  and  mounting  in  balsam.  K  complete  bibliography  of  noma 
is  given  by  Weaver  and  Tunnicliff.^ 

Symptoms. — The  cheek  will  appear  swollen,  hard,  and  oedematous  to 
the  touch,  the  oedema  causing  such  .swelling  that  frequently  the  eye  of  the 
affected  side  cannot  be  opened.  There  is  a  decided  fetor  to  the  breath, 
which  is  often  the  first  symptom  noticed.  The  disease  spreads  very  rapidly 
from  tlie  gums  to  the  cheek.  Frequently  the  teeth  will  loosen  and  fall 
out.  The  latter  is  frequently  caused  by  the  previous  administration  of 
mercury.  Thus  it  is  that  great  care  should  be  used  in  giving  mercurj'  to 
children. 

That  it  is  not  an  inflammatoi'y  disease  can  be  seen  by  the  fact  that 
the  temperature  is  rarely  or  never  above  normal.  The  swelling  can  best 
be  felt  by  opening  the  mouth  and  grasping  the  cheek  between  the  thumb 
and  forefinger.  The  skin  over  the  induration  is  frequently  mottled  with 
purple  spots  resembling  ecchymoses.  The  appetite  is  diminished,  partly 
due  to  the  fear  of  pain  caused  by  chewing. 

Some  authorities  state  that  children  so  affected  have  diarrhoea.  Forch- 
heimer  believes  that  ha?morrhages  rarely  occur,  owing  to  the  blood-yessels 
being  filled  with  thrombi. 


^Arcli.  fiir  klin.  Chir.,  1899,  lix. 

*  Journal  of  Infectious  Diseases,  1907. 

'Journal  of  Infectious  Diseases,  Jan.,  1907. 


213  DISEASES  OF  THE  MOUTH. 

When  this  gangrenous  mass  discharges  we  will  find  a  dirty,  fetid 
saliva,  with  threads  of  broken-down  tissue.  The  cervical  glands  in  the 
immediate  vicinity  are  always  found  enlarged.  In  severe  cases  it  is  not 
rare  to  have  the  parts  ulcerate  and  even  perforate  the  cheek  after  several 
days.  When  the  disease  extends  inward,  not  only  does  periostitis  occur,  but 
necrosis  of  the  jaw-bone  has  been  noted.  When  the  disease  is  as  malignant 
as  has  just  been  described,  then  subnormal  temperature,  possibly  delirium, 
may  complicate  the  condition.    The  disease  may  extend  to  the  lungs,  caus- 


Fig.  56. — Case  of  Stomatitis  Gangrenosa  (Noma)  Following  Scarlet 
Fever.  The  picture  shows  the  unilateral  gangrenous  condition  involving 
the  right  cheek  and  the  lips.  Case  recovered.  Clinical  history  given  in 
the  text.     (Original.) 


ing  a  gangrenous  infiltration.     When  the  gangrene  affects  the  genitals  in 
girls,  then  a  serious  prognosis  must  be  given. 

The  following  cases  will  illustrate  the  condition  described : — 

Elsie  G.,  aged  7  years,  was  seen  by  me  in  January,  1900.  The  child  had  com- 
plained of  severe  headache  for  three  or  four  days,  and  was  very  feverish.  Her 
mother  became  alarmed  because  of  persistent  vomiting.  She  stated  that  the  child 
vomited  at  least  six  times  in  twenty-four  hours.  She  complained  of  feeling  fatigued 
and  had  pains  in  her  arms  and  legs. 

The  child  was  nursed  for  ten  months,  and  was  a  strong  baby  up  to  this  time; 
dentition  commenced  at  the  seventh  month;  the  child's  muscles  and  bones  were 
well  developed;  there  were  no  evidences  of  rickets;  the  first  two  years  were  passed 


NOMA.  313 

without  any  sickness  except  an  occasional  attack  of  constipation.  The  child  walked 
at  the  end  of  the  first  year  and  commenced  talking  at  its  fourteenth  month.  Twenty 
teeth — "milk  teeth" — appeared  at  the  end  of  two  years.  The  child  had  measles  in  its 
third  year,  which  left  a  bronchitis;  the  mother  states  that  this  same  cough  recurs 
every  winter.  The  child  had  had  whooping-cough,  lasting  four  months,  which  was 
so  violent  that  it  had  epistaxis  almost  every  day  for  one  month.  This  whooping- 
cough  was  so  severe  that,  in  addition  to  the  nose-bleed,  the  child  vomited  almost 
continuously.  From  loss  of  sleep,  in  addition  to  the  above-named  symptoms,  the 
child  commenced  to  emaciate.     This  was  at  the  end  of  her  fifth  year. 

Wlien  the  child  was  undressed  an  eruption  was  found  all  over  the  body,  which 
was  that  of  typical  scarlet  fever.  The  throat  was  filled  with  evidences  of  pseudo- 
membranous patches,  which  were  distinctly  scarlatinal  in  character.  The  tempera- 
ture was  103.4°  F.,  taken  in  the  rectum;  pulse,  128;  respiration,  22.  The  child 
was  put  to  bed  and  an  expectant  plan  of  treatment  ordered,  in  addition  to  a  very 
light  liquid  diet  consisting  of  soup,  milk,  buttermilk,  broth.  Nothing  else  was 
allowed;  no  solids  were  given.  For  the  thirst  I  ordered  orange  juice  and  apple 
sauce.  Small  doses  (wine-glasses)  of  citrate  of  magnesia  were  given  for  their  laxa- 
tive and  diuretic  effects. 

The  heart  sounds  were  very  feeble,  and  a  loud,  blowing,  hsemic  murmur,  which 
was  attributed  to  the  anaemic  condition,  was  audible.  Iron  was  given  in  the  form 
of  the  syrup  of  iodide  of  iron;  hypophosphites  were  also  administered  as  restoratives. 
Convalescence  lasted  in  all  until  April,  a  period  of  almost  three  months  from  the 
time  of  the  child's  first  illness.  About  this  time  she  complained  of  pain  in  the  gums 
and  on  the  cheek  while  chewing.  Later,  the  foul  breath  attracted  attention.  At  first 
this  condition  was  attributed  to  the  teeth,  but  a  dentist  who  saw  the  child  found  the 
teeth  and  gums  healthy.  The  ulceration,  which  had  now  become  quite  marked,  from 
the  size  of  a  silver  dollar,  spread  with  remarkable  rapidity.  Its  color  was  that  of  a 
dirty,  blackish  gray,  and  had  purpuric  spots  scattered  around  the  edges  of  this 
ulceration,  resembling  subcutaneous  haemorrhages.  On  examining  it  considerable 
fluid,  which  was  very  foul  smelling,  exuded  on  pressure.  Antiseptic  lotion,  consisting 
of  50  per  cent,  peroxide  of  hydrogen  diluted  with  water,  was  ordered  as  a  mouth 
wash.  The  child  was  told  to  rinse  the  mouth  every  half-hour,  especially  after  eating. 
The  gangrene  extended  to  the  outside  of  the  cheek,  involving,  as  can  be  seen  by  the 
illustration,  almost  the  whole  cheek. 

The  streptothrix  is  usually  present  in  the  pregangrenous  stage  and  it  is 
here  in  this  stage  that  the  best  therapeutic  results  are  attained.  As  a  rule, 
the  disease  appears  in  epidemic  form.  In  diphtheria,  scarlet  fever,  and  espe- 
cially measles  oral  hygiene  must  be  instituted  to  prevent  stomatitis,  and 
especially  ulcerative  stomatitis.  The  latter  is  frequently  a  soil  for  the  de- 
velopment of  noma  and  hence  every  case  of  stomatitis  should  receive  active 
treatment  to  prevent  gangrene. 

The  following  case  was  seen  by  me  at  the  Willard  Parker  Hospital  dur- 
ing my  service  in  April,  1913  : — 

Child  C,  3  years  old,  was  admitted  with  a  moderately  severe  type  of  scarlet 
fever.  Later  a  complication  of  noma  developed,  and  this  was  the  reason  for  the 
injection  of  0.2  neosalvarsan.  Within  three  days  after  the  injection  a  slight  im- 
provement was  noted,  which  continued  steadily  until  the  case  recovered,  in  all  ten 
days  from  day  of  first  injection.  The  noma  involved  the  pharynx,  tonsils,  and  soft 
palate. 


214  DISEASES  OF  THE  MOUTH. 

When  fetor  of  the  breath  exists,  a  strong  solution  of  permanganate  of 
potassiiun  as  a  gargle  or  spray  every  two  hours  will  deodorize.  Internally 
tincture  of  iron  as  a  restorative.  The  insufSation  of  a  small  quantity  of 
neosalvarsan  used  locally  once  a  day  is  advised.  If  fever  exists,  and  toxaemia 
complicates,  an  intravenous  injection  of  0.2  neosalvarsan  dissolved  in  40 
c.c.  of  sterile  water  and  injected  into  the  jugular  vein  has  shown  marked 
improvement  in  a  number  of  my  cases. 

Epithelial  Desquaiiation  (Geographical  Tongue). 

A  very  common  condition  consists  of  epithelial  desquamation  of  the 
tongue,  giving  rise  to  irregular,  round  or  crescent-shaped  patches.  The 
borders  of  these  patches  are  surrounded  by  a  thickish,  grajash  margin.  The 
center  has  a  glazed  appearance.  From  the  irregular  outline  resembling  a 
map  the  name  of  geographical  tongue  originates. 

There  are  usually  two  or  more  of  these  red  patches  seen  at  one  time. 
They  last  weeks  and  months.  I  have  met  these  cases  among  the  poorest 
hygienic  surroundings  and  have  seen  the  same  condition  among  the  wealthy. 
Malnutrition  seems  to  be  associated  in  all  my  cases,  I  have  frequently  seen 
eases  of  this  kind  among  the  children  suffering  with  diphtheria  at  the 
WillaTd  Parker  Hospital,  especially  during  convalescence.  The  following 
case  illustrates  this'  condition : — 

Minnie  H.  Fourteen  months  old.  Has  been  in  delicate  health  since  birth. 
Although  breast-fed,  has  always  been  constipated  and  suffered  with  gastritis,  and 
vomiting  occasionally. 

She  is  very  anaemic.  Can  neither  stand,  walk,  nor  talk.  Dentition  has  been 
delayed;  there  is  no  sign  of  teeth.-  The  tongue  shows  four  large,  irregular  shaped 
patches  and  tsvo  smaller  ones  in  the  center.  They  appear  as  though  a  coated 
tongue  had  irregular  patches  of  red,  and  shining  flesh  interspersed.  Diagnosis, 
rickets  and  geographical  tongue. 

Treatment. — Increase  the  proteins  and  fats  to  stimulate  nutrition. 
Cleanse  the  tongue  with  boric  or  tannic  acid  solution.  Most  authors  advise 
no  treatment. 

Congenital  HypeflTrophy  of  the  Tongue. 

A  thickened,  swollen  tongue  is  always  seen  in  sporadic  cretinism.  (See 
chapter  on  ^'Cretinism .'^)  The  specific  thyroid  treatment  will  usually 
modify  this  enlargement.  When  diseased  lymphatics  exist  we  may  have 
a  lymphangioma.  Such  conditions  are  rare,  and  if  present  require  surgical 
treatment. 

Bifid  Tongue. 

Brothers  reported  a  case  of  this  kind  to  the  New  York  Pathological 
Society.  The  child  was  one  month  old,  had  a  cleft  tongue  and  a  fissure  of 
the  soft  palate. 


PLATE  VII 


Greographical  Tongue,  or  Epithelial  Desquamation. 
(Original.) 


ALVEOLAR  ABSCESS.  215 

Bifid  Uvula. 

This  condition  is  occasionally  seen.  I  have  seen  bifid  uvula  several 
times  without  cleft  palate.  Some  authors  report  the  co-existence  of  bifid 
uvula  with  cleft  palate.    It  requires  no  treatment. 

Glossitis. 

An  inflammation  of  the  tongue  is  very  rare  in  children.  Some  authors 
state  that  it  is  due  to  traumatism,  such  as  biting  the  tongue  in  an  epileptic 
fit,  or  a  ragged,  sharp  tooth  may  infect  the  tongue  and  cause  inflammation. 
Any  irritation,  such  as  caustic  acids  or  alkalies,  may  cause  inflammation. 

The  following  case  occurred  in  my  private  practice : — 

A  child  1  year  old  was  bottle-fed,  and  suffered  witli  severe  constipation.  He 
was  backward  in  development,  had  no  teeth,  could  neither  walk  nor  talk.  Several 
adults  in  the  family  had  influenza  and  the  child  was  exposed  and  infected.  The 
fever  reached  104°  F.  There  was  anorexia,  cough,  and  running  of  the  nose.  The 
tongue  was  thickened  and  inflamed  and  protruded  from  the  mouth.  He  refused  to 
take  any  food  and  seemed  relieved  when  a  piece  of  ice  was  placed  on  the  tongue. 
Ice  cream  was  ordered  to  nourish  and  cool  at  the  same  time.  Rectal  suppositories 
containing  aconite,  1  minim,  and  sodium  salicylate,  3  grains,  were  ordered  every  two 
hours.  Under  this  treatment,  aided  by  ice  applied  on  the  tongue  and  an  ice  collar 
on  the  neck,  the  swelling  of  the  tongue  disappeared  in  about  four  days. 

Eanula. 

A  swelling  in  the  floor  of  the  mouth,  located  on  either  side  of  the 
fraenum,  is  frequently  met  with  in  children.  It  is  a  cyst  varying  in  size, 
and  is  due  to  an  occlusion  of  the  duct  leading  into  the  mouth  from  the 
sublingual  gland. 

Character. — It  may  be  simple  or  multilocular.  It  may  be  of  such  pro- 
portions as  to  interfere  with  proper  nutrition. 

Symptoms. — ^The  symptoms  are  those  of  a  mechanical  obstruction  of 
a  non- inflammatory  character.  It  is  painless,  soft,  fluctuating,  and  con- 
tains mucus.  The  color  of  the  growth  is  the  same  as  that  of  the  adjacent 
parts. 

Treatment. — An  incision  should  be  made  to  evacuate  the  contents  of 
the  sac.  The  interior  of  the  sac  should  be  cauterized  with  iodine  or  nitrate 
of  silver.    In  some  instances  the  Paquelin  cautery  may  be  required. 

Alveolar  Abscess. 

When  there  is  defective  hygiene  in  the  mouth  and  the  teeth  are  not 
properly  cleaned,  caries  of  the  teeth  results.  The  carious  condition  fre- 
quently sets  up  an  inflammation,  and  pyogenic  bacteria,  gaining  entrance, 
cause  abscess  formation  at  the  root  of  the  tooth. 


216  DISEASES  OF  THE  MOUTH. 

Symptoms. — The  symptoms  are  pain,  swelling,  fever,  interference  with 
feeding,  foul  breath,  and  general  constitutional  disturbances.  The  diag- 
nosis can  be  made  by  the  presence  of  fluctuation  in  the  mouth,  by  the 
swollen  face,  mouth,  and  jaw. 

Treatment. — Locally,  warm  (dry)  chamomile  bag  or  warm  (moist) 
flaxseed  poultices  will  have  a  soothing  effect,  used  externally  over  the  swell- 
ing. Einsing  the  mouth  with  warm  chamomile  tea  to  which  a  few  drops 
of  listerine  have  been  added  is  grateful.  Painting  the  gums  with  equal  parts 
of  tincture  of  iodine  and  tincture  of  opium  every  hour  will  relieve  pain. 
If  fluctuation  is  detected  an  incision  should  be  made  into  the  gums  on  the 
inner  surface,  and  the  pus  evacuated.  If  this  condition  is  neglected  the 
periosteum  of  the  jaw  may  be  involved  and  the  pus  will  burrow  and  evacuate 
itself  spontaneously,  leaving  a  disagreeable  fistula.  Cases  have  been  reported 
where  neglect  of  this  condition  has  resulted  in  necrosis  of  the  jaw. 

Angina  Ludovici. 

Angina  Ludovici  is  an  inflammation  of  the  cellular  tissue  of  the  floor 
of  the  mouth  and  neck.  It  is  probably  a  form  of  actinomycosis.  The 
swelling  is  most  marked  below  the  jaw  of  one  side.  The  symptoms  are 
very  intense  and  both  local  and  general.  There  are  general  septic  symptoms 
from  the  outset.  With  the  swelling  there  are  oedema  and  board-like  indura- 
tion. Eedness  and  the  rapid  formation  of  an  abscess  occur  rarely.  The 
throat  is  not  affected.  Death  takes  place  from  reflex  suffocation  or  in 
coma. 


CHAPTER  II. 
DISEASES  OF  THE  (ESOPHAGUS. 

Acute  G^Isophagitis. 

An  mflammation  may  extend  from  the  pharynx  into  the  oesophagus. 
When  such  conditions  arise  the  symptoms  of  pain  on  swallowing  are  asso- 
ciated with  fever.  The  treatment  consists  in  giving  bland  food,  milk, 
seltzer,  and  alkaline  waters  or  water  containing  bicarbonate  of  soda. 

Croupous  or  Diphtheritic  (Esophagitis. 

Diphtheria  can  invade  the  oesophagus  as  well  as  it  can  spread  to  the 
larynx.  Some  authors  describe  croupous  inflammatory  patches  in  the 
oesophagus.  I  have  seen  diphtheria  of  the  oesophagus  and  also  a  diph- 
theritic patch  post-mortem  in  the  stomach  of  this  same  case.  Such  a  con- 
dition is  invariably  serious  and  recovery  is  rare.  The  treatment  of  diph- 
theria affecting  the  msophagtis  is  the  same  as  that  described  in  the  chapter 
on  "Diphtheria."  When  dysphagia  occurs  and  there  is  an  interference  with 
deglutition,  rectal  feeding  may  be  demanded  to  save  life. 

If  severe  pain  exists  morphine  or  codeine  in  suitable  doses.  Nau- 
sea and  vomiting  can  best  be  controlled  by  giving  large  doses  of  chloral.  If 
an  oesophageal  stricture  remains,  then  surgical  treatment  will  be  required, 
for  which  the  reader  is  referred  to  modern  text-books  on  surgery. 

Eetro-gesophageal  Abscess. 

This  condition  may  follow  measles,  scarlet  fever,  or  diphtheria ;  in  fact, 
it  may  be  associated  with  any  infectious  disease.  As  a  rule,  this  disease  con- 
sists of  a  breaking  down  of  the  lymph  glands  ending  in  suppuration.  In 
a  case  seen  by  me  the  streptococcus  was  found.  This  condition  is  also 
frequently  associated  with  tubercular  conditions.  The  following  case  will 
illustrate  the  type  most  frequently  met  with : — 

I  was  called  in  consultation  with  Dr.  S.  Brothers  to  see  a  child  3  years  old 
with  the  following  history: — 

There  was  fever,  an  irritant  cough,  stertorous  breathing,  and  evidence  of 
obstruction  pointing  to  the  larynx.  The  neck  was  swollen  and  the  glands  enlarged. 
The  temperature  was  102°  F. ;  pulse,  130;  respiration,  36.  At  first  the  case  resem- 
bled one  of  laryngeal  stenosis  as  is  usTially  found  in  diphtheria.  The  dyspnoea  was 
so  marked  that  intubation  was  suggested.     The  symptoms  of  dyspnoea  continued, 

(217) 


218  DISEASES  OF  THE  (ESOPHAGUS, 

and.  an  incision  was  made  into  the  posterior  pharyngeal  wall.  The  abscess  cavity 
extended  into  the  oesophagus.  Caries  of  the  dorsal  vertebrae  was  associated  with 
this  condition.  The  child  died  from  inanition.  The  tubercular  process  was  evidently 
responsible  for  the  abscess,  which  consisted  of  pus  and  large  curded  masses.  The 
diagnosis  was  made  after  a  careful  study  of  the  case.  It  is  not  an  easy  matter  to 
diagnose  this  condition,  as  it  is  absolutely  impossible,  in  some  cases,  to  reach  the 
abscess  cavity  by  a  digital  examination  of  the  pharynx. 

In  the  case  above  reported  the  dyspnoea  was  very  alarming.  The  litera- 
ture records  cases  of  spontaneous  evacuation  of  the  abscess  into  the  oesoph- 
agus resulting  in  recovery,  but  usually  these  cases  end  fatally.  The  treat- 
ment is  surgical,  and  tuberculosis,  if  present,  requires  the  usual  form  of 
treatment.     (See  chapter  on  "Tuberculosis.") 


Fig.  57. — Hinged  Bucket. 


Foreign  Bodies  in  the  CEsophagus. 

I  have  frequently  been  consulted  regarding  the  removal  of  buttons, 
coins,  etc.,  which  were  swallowed.  The  habit  of  children  to  put  everything 
into  the  mouth  should  be  remembered  when  buying  toys. 

The  best  method  of  extracting  foreign  bodies  in  the  oesophagus  is  by 
means  of  the  hinged  bucket ;  also  known  as  the  "coin  catcher." 


CHAPTER  III. 

DISEASES  OF  THE  STOMACH. 

Acute  Gastric  Catarrh  (Dyspepsia;  Gastritis). 

One  of  the  most  frequent  diseases  met  with  in  infants  or  young  chil- 
dren is  dyspepsia.  This  is  due  to  improper  feeding  of  both  quality  and 
quantity  of  the  food.  Nursing  children  are  very  often  seen  suffering  with 
this  disease,  especially  among  the  tenement  population.  That  poor  hygiene 
has  some  bearing  on  the  development  of  this  disease  is  certain. 

The  largest  number  of  cases  are  seen  with  bottle-fed  babies.    Errors  in- 
feeding,  particularly  over-feeding,  and  giving  the  infant  the  bottle  whenever 
it  cries,  must  be  looked  upon  as  a  means  of  aggravating  and  exciting 
gastritis,  if  not  being  the  real  cause  of  the  dyspepsia. 

Pathology. — The  mucous  membrane  of  the  stomach  is  always  swollen 
and  thickened.  Occasionally  erosions  and  hgemorrhages  are  found.  The 
tissue  beneath  the  mucous  membrane,  the  submucosa,  will  be  found  oedema- 
tous.  The  interstitial  tissue  is  infiltrated  with  leucocytes,  and  the  differen- 
tiation between  the  parietal  and  principal  cells  cannot  be  clearly  outlined. 
All  the  cells  appear  cloudy  and  granular  and  partially  separated  from  the 
membrana  propria  of  the  gland.  There  is  an  abundance  of  the  mucous 
cells  in  the  pyloric  region,  and  this  increase  extends  deeply  into  the  ducts 
of  the  glands. 

In  older  children  the  origin  of  the  trouble  can  easily  be  traced.  Over- 
eating, especially  cakes  and  pies  and  puddings;  too  rapid  chewing  and 
swallowing  of  unmasticated  pieces  will  aggravate  an  attack  of  this  kind. 

Gastritis  is  seen  more  often  in  older  children  who  are  permitted  to 
drink  wine  or  beer  at  the  table  with  their  parents.  Children  are  permitted 
a  drop  of  whisky  or  wine  or  beer,  as  their  parents  say,  "to  strengthen  them." 
Candies  and  ice  creams  frequently  cause  acute  gastritis,  in  children. 

Symptoms. — A  young  infant  will  suddenly  refuse  to  take  its  bottle  and 
will  appear  very  peevish  and  thirsty,  flex  its  legs  on  its  abdomen,  will  seem 
dissatisfied,  and  refuse  to  play.  Vomiting  is  a  frequent  symptom.  The 
infant  will  cry  and  put  its  fingers  into  its  mouth.  The  temperature  on  the 
first  day  ranges  between  102°  and  103°  F.,  though  it  may  reach  as  high  as 
105°  F.  in  the  rectum.  The  pulse  ranges  between  140  and  160.  The  res- 
piration is  sometimes  accelerated.  The  tongue  is  usually  coated  with  a 
white  or  a  grayish-white  fur,  and  there  is  a  foetid  odor  to  the  breath.  Diar- 
rhoea may  be  present,  although  constipation  is  more  frequently  met  with. 

When  children  are  extremely  antemic,  or  if  from  previous  malnutrition 
they  are  rachitic,  the  disease  will  commence  with  convulsions.    Convulsions 

(319) 


220  DISEASES  OF  THE  STOMACH. 

must  not  be  looked  iiiDon  as  very  serious  unless  they  recur  several  times 
during  the  first  day  of  the  attack. 

A  diagnosis  of  meningitis  will  frequently  be  made  in  the  commence- 
ment of  an  acute  catarrhal  gastritis,  unless  we  study  the  pulse-rate.  In 
meningitis  the  pulse-rate  is  usually  slow ;  in  gastritis  it  is  greatly  accelerated. 
Pressure  on  the  epigastrium  Avill  show  marked  tenderness.  The  stomach 
is  usually  distended  and  tympanitic  on  percussion. 

If  a  child  is  old  enough  to  complain,  there  are  usually  subjective  symp- 
toms such  as  headache,  frontal  in  character,  and  pains  in  the  arms  and 
legs  will  be  described.  Jaundice  will  usually  be  found  in  older  children  in 
the  course  of  the  disease,  and  denotes  an  extension  of  the  catarrhal  inflam- 
mation from  the  stomach  into  the  duodenum;  thus  gastro-duodenitis  may 
'be  diagnosed  when  jaundice  is  established. 

Prognosis  and  Course. — The  prognosis  of  an  acute  catarrhal  gastritis 
depends  on  the  time  of  the  year  and  the  condition  of  the  child  at  the  time 
of  the  attack.  If  a  bottle-fed  infant  is  attacked  with  gastritis  in  midsum- 
mer, and  it  cannot  be  removed  from  the  sultry  city,  then  the  prognosis  is 
grave.  If,  however,  breast-milk  can  be  given  judiciously  and  the  feeding 
interval  conform  with  the  requirements  of  the  weak  digestive  apparatus, 
then  we  may  reasonably  hope  for  a  favorable  termination.  If  complications 
occur,  chief  among  which  may  be  typhoid  fever,  or  an  extension  of  the 
disease  from  the  stomach  into  the  bowel,  then  the  outlook  will  not  be  good, 
unless  we  can  remove  the  patient  to  the  mountains  or  seashore. 

Nephritis  frequently  complicates  gastritis,  and  when  such  complica- 
tions exist  the  prognosis  is  bad.  Infectious  diseases  complicating  gastritis 
will  render  the  prognosis  unfavorable. 

The  important  point  to  note  is,  how  much  food  is  being  assimilated. 
If  the  infant  digests  a  proper  quantity  of  food  the  prognosis  is  good;  if, 
however,  vomiting  continues  and  we  cannot  feed  the  child  per  mouth  or 
per  rectum,  then  the  prognosis  is  very  grave.  We  must  aim  to  prevent 
starvation  if  the  child's  life  is  to  be  saved. 

Treatment. — The  first  thing  to  do  is  to  cleanse  the  stomach.  This  can 
be  accomplished  by  giving  a  dose  of  castor-oil,  syrup  of  rhubarb,  or  calomel. 
If  the  child  is  old  enough  some  citrate  of  magnesia  in  wineglassful  doses, 
repeated  every  two  or  three  hours,  will  correct  fermentation.  When  rapid 
cleansing  of  the  stomach  is  demanded,  owing  to  toxic  symptoms  from 
ptomaine  poisoning  or  from  other  poisons,  an  emetic  should  be  given.  A 
dose  of  1  grain  of  sulphate  of  copper  in  a  teaspoonful  of  water,  repeated 
every  half-hour  until  vomiting  is  produced,  will  materially  aid  in  cleansing 
the  stomach.  Syrup  of  ipecac,  in  teaspoonful  doses,  may  also  be  given  in 
some  instances,  although  the  writer  does  not  advocate  the  use  of  syrups  in 
acute  fermentative  diseases  of  the  stomach  or  bowels.  In  other  cases  wash- 
ing the   stomach  with   a   soft   catheter,   as   mentioned   in  the   treatment 


A.CUTE  GASTRIC  CATARRH.  221 

of  summer  complaint,  will  prove  very  valual)le.  Several  pints  of  table  salt 
solution  or  of  noniuil  salt  solution^  can  be  used  to  tboroughly  cleanse  the 
stomach  until  the  water  is  syphoned  oft'  quite  clear.  In  washing  the  stomach 
wjth  the  aid  of  a  sol't-rul)l)cr  catheter  there  is  usually  (piite  some  irritation 
produced  in  the  pharynx  and  oesophagus,  and  thus  vomiting  will  usually 
aid  in  the  lavage  in  clearing  the  stomach  of  its  contents.  When  such  treat- 
ment has  been  instituted  it  is  advisable  to  allow  tlie  stomach  to  rest  at  least 
six  or  seven  hours,  and  meanwhile  give  sterile  water — "ordinary  jjoiled 
water" — ad  Uhituni. 

When  the  bowels  have  been  properly  cleansed  and  the  stomach  has 
been  washed  by  lavage,  or  treated  wdtli  one  of  the  above-mentioned  laxa- 
tives, then  the  after-treatment  will  consist  in  preventing  further  fermen- 
tation, and  also  in  toning  up  the  patient's  condition. 

Medicinal  Treatment. — Experiments  have  shown  that  when  the  gastric 
contents  have  been  syphoned  off  or  examined  immediately  after  an  emetic 
has  been  given,  in  an  acute  gastritis,  there  is  a  deficiency  of  hydro- 
chloric acid.    This  is  an  indication  then  as  to  what  is  required. 

Diluted  hydrochloric  acid  given  in  doses  of  from  2  to  5  drops  has 
served  the  writer  very  well  wdien  given  every  three  or  four  hours. 

IJ   Acid   hydrochloric   dilut 1   drachm 

Essence  pepsin    ( Faircliild)     2  ounces 

M.  D.  S.     Teaspoonful  repeated  every  two  or  three  hours. 

Beta-naphthol  bismuth  in  doses  of  1  to  5  grains,  every  two  hours,  has 
served  me  very  well.  Calcined  magnesia^  is  also  very  valuable.  The  fol- 
lowing prescription  has  been  used  with  very  good  results  in  dyspeptic  con- 
ditions attended  with  constipation  : —    . 

IJ  Magnesia  usta    1   drachm 

Pulv.  rhei    1  draclim 

Saccharum' 2  grains 

M.  and  divide  into  12  powders.  One  powder  to  be  given  in  a  teaspoonful  of 
sterile  water  every  two  or  three  hours. 

Powdered  charcoal  added  to  the  above  prescription  in  doses  of  1  grain 
three  times  a  day  is  frequently  useful.  Salol  in  doses  of  1  grain  every  two 
or  three  hours,  and  resorcin  in  doses  of  ^/m  grain  or  i/4  gi'ain,  for  a  child 
1  year  old,  repeated  three  times  a  day,  will  do  good  in  some  instances. 

A  very  good  liquid  preparation  sold-  in  drug  stores  is  milk  of  magnesia 
(Phillip's).  It  is  an  excellent  antacid  and  corrective  when  flatulence 
exists. 

^Formula?  for  saline  solutions  will  be  found  in  the  chapter  on  "Scarlet  Fever." 
-  Magnesia  in  powdered  form  I  frequently  use  is  known  as  Husband's  Magnesia 
in  drug  stores. 


223  DISEASES  OF  THE  STOMACH. 

"When  severe  thirst  exists  boiled  water  ma}'  be  given.  This  water  may 
be  acidulated  with  a  few  drojos  of  diluted  i^hosphoric  acid,  and  will  be 
found  not  onh'  very  grateful  and  cooling,  but  very  serviceable  if  the  child 
has  a  tendency  to  diarrhoea  in  midsummer. 

Dietetic  Treatment. — The  most  important  point  to  remember  is  the 
feeding.  If  we  are  dealing  with  the  nursling,  then  breast-milk  should  be 
withheld  for  about  one-half  day.  When  the  breast  is  given  again,  the  infant 
should  not  be  permitted  to  nurse  more  than  two  or  three  minutes,  and 
immediately  after  taking  the  breast  the  infant  should  receive  3  or  4  ounces 
of  sweetened  rice  water.  In  this  manner  we  will  give  the  infant  diluted 
milk.  This  breast  and  rice-water  feeding  should  be  repeated  in  four  hours, 
no  sooner,  no  matter  what  the  age  of  the  infant. 

"What  might  appear  very  radical  is  simply  advised,  to  prevent  the  stom- 
ach from  performing  its  usual  amount  of  work  until  the  gastric  function 
is  reestablished.  If,  however,  the  child's  appetite  warrants  it^  then  one  or 
two  days  should  elapse  before  giving  it  its  former  regular  quantity  of  nurs- 
ing. The  guide  to  the  return  of  the  normal  quantity  of  nursing  will  be  the 
disappearance  of  the  fever  and  of  the  accelerated  pulse-rate.  The  child's 
craving  for  the  breast  can  be  noted  chiefly  by  constant  crying  when  the 
breast  is  removed,  and  the  ravenous  manner  in  which  it  nurses. 

In  bottle-fed  babies  it  is  advisable  to  give  the  child  one-half  of  the 
former  quantity  of  milk  or  cream  which  it  received  at  the  time  of  its  illness,, 
and  if  it  is  found  that  the  sugar  contained  in  the  food  aggravates  this  con- 
dition, a  small  quantity  of  saccharine  may  be  used  to  sweeten  the  milk,  and 
the  sugar  discontinued.  Some  children  show  distinct  fermentative  changes 
after  the  use  of  too  much  sugar.  In  such  cases  the  use  of  saccharine  or  one- 
half  teaspoonful  of  glycerine  to  each  bottle  of  milk  is  sometimes  beneficial 
as  a  temporary  substitute. 

Glycerine  is  al:)Solutely  harmless  and  may  be  given  for  months  with 
impunity.  My  rule  is  to  insist  on  the  use  of  sugar  if  at  all  possible.  Lime 
water  in  doses  of  a  teaspoonful  or  a  tablespoonful  may  be  added  to  the 
milk.  Five  grains  of  bicarbonate  of  soda  may  be  added  to  the  milk  or 
given  Ijefore  each  feeding.  If  vomiting  follows  the  milk-feeding,  whey 
should  be  substituted. 

Attention  must  be  paid  to  the  quality  of  milk  given  to  infants.  There 
are  many  dairies  in  Xcav  York  City  which  furnish  an  excellent  quality  of 
milk,  owing  to  the  great  care  liestowed  upon  the  milk  supply  by  the  Health 
Department,  and  also  by  the  Milk  Commission. 

If  milk  seems  to  aggravate  an  attack  of  dyspepsia,  then  zoolak  or 
kumyss  or  other  fermented  milk  may  be  tried.  Buttermilk  is  very  nour- 
ishing and  very  useful  in  dyspepsia.  Junket  may  also  be  tried;  so  also  can 
whey  be  given  several  times  a  day.  Soups  and  broths,  calf's  foot  and  chicken- 
jellies  are  all  nourishing.     Steak  juice  and  unfermented  grape  juice  will 


ACUTE  GASTRIC  CATARRH.  223 

be  serviceable.  Boiled  fruits,  such  as  apples  and  peaches,  if  the  child  is  old 
eriou<Tjli  and  the  condition  warrants  it,  may  be  tried. 

Our  aim  must  be  to  have  the  infant  fed  with  a  large  interval  of  rest, 
so  that  nausea  and  vomiting  may  be  prevented,  and  in  order  tliat  the  food 
may  be  properly  assimilated.  "We  must  therefore  give  small  quantities  with 
large  feeding  intervals.  When  the  functions  are  again  normal  then  we  can 
return  to  a  judicious,  nutritious  diet,  as  demanded  by  the  infantile  stomach. 
It  is  advisable  to  give  nux  vomica  in  doses  of  1  minim  for  a  child,  1  to  3 
years  old,  three  times  a  day  Ijefoi-e  feeding,  and  to  continue  the  same  for 
months  after  the  gastritis  disappears.  The  writer  has  seen  the  most  marked 
improvement  following  the  use  of  this  drug,  and  regards  it  as  a  specific  for 
toning  the  stomach. 

Malt  extract  should  be  given  in  doses  of  a  half  teaspoonful,  three  times 
a  day,  to  aid  nutrition.  It  is  well  known  that  malt  lias  a  decided  laxative 
effect.  Care  should  be  taken  that  fermentation  is  not  reestablished  while 
giving  malt.  In  some  cases  it  is  not  well  borne  in  the  commencement  of  an 
acute  gastritis,  and  a  total  abstinence  of  milk  and  the  substitution  of  boiled 
water,  whey,  soups,  and  .broths  may  become  necessary;  very  weak  tea,  to 
which,  the  white  of  a  raw  egg  has  been  added  find  sweetened  with  saccharine 
or  with  granulated  sugar,  can  be  given  with  advantage. 

Fever. — The  temperature  in  the  course  of  an  acute  gastritis  requires 
no  antipyretic  treatment,  although  sponging  the  surface  or  a  cold  pack, 
applied  over  the  thorax  and  abdomen,  will  be  serviceable.  Specific  fever 
treatment  is  uncalled  for.  The  well-known  depressing  effect  of  antipyretic 
drugs  must  not  be  forgotten,  and  hence  the  specific  cause  of  the  disease 
must  be  removed.  This  is  usually  stagnant  food.  The  same  requires  clean- 
ing out  with  calomel  or  cascara.  The  cause  of  the  fever  will  be  removed 
with  such  effectual  treatment. 

When  children  have  a  tendency  to  convulsions  then  a  mustard  foot- 
bath can  be  given  and  an  ice-bag  applied  over  the  anterior  fontanel,  or 
at  the  nape  of  the  neck.  In  such  instances  the  most  rapid  treatment  will 
be  called  for,  such  as  washing  the  stomach  with  a  catheter,  using  warm  salt 
water.  An  emetic  will  prove  useful  in  those  cases  where  lavage  cannot  be 
successfully  carried  out. 

Alcoholic  stimulation  is  contraindicated  in  every  form  of  gastric  fever. 
The  writer  has  always  seen  bad  results  follow  the  use  of  whisky  when  the 
gastric  mucous  membrane  was  inflamed.  If,  however,  the  ])atient  is  threat- 
ened with  collapse,  or  the  pulse  is  very  weak,  then  snuiU  doses  of  musk  in 
the  form  of  a  tincture  of  musk  can  be  injected  hypodermically,  every  hour, 
until  the  pulse-rate  improves.  Camphorated  oil,  injected  hypodermically,  in 
doses  of  from  5  to  15  minims,  may  do  good  in  some  cases. 

Hot  coffee  may  be  given  in  small  doses,  two  or  three  teaspoonfuls 
repeated  every  fifteen  minutes,  until  its  physiological  effect  is  manifested. 


224  DISEASES  OF  THE  STOMACH. 


Pyloric  Obstruction  Caused  by  Spasm  of  the  Pylorus. 

The  sjaiiptoms  of  obstruction  of  the  p^^lorxis^  clue  to  spasm  or  obstruc- 
tion clue  to  hypertrophy,  are  strikingly  similar.  It  is  difiicult  to  differen- 
tiate the  same  in  many  cases.  In  the  one,  the  spasm  is  a  benign  condition 
which  yields  to  and  is  frequently  overcome  by  mild  and  palliative  remedies. 
In  stenosis,  however,  we  have  a  serious  condition  and  one  that  has  cost  many 
lives,  despite  proper  surgical  measures. 

Causes. — The  most  frequent  cause  of  pyloric  spasm  in  infancy  is  due 
to  irritating  food,  that  is,  food  containing  excessive  high  fat  and  high 
proteids.  Another  cause  of  j^yloric  irritation  resulting  in  spasm  is  seen 
when  human  milk  is  suddenly  withdrawn  and  cows'  milk  substituted.  When 
there  is  deficient  peptic  secretion,  including  hyperacidity,  such  condition  as 
spasm  may  be  caused  by  stagnation  of  the  gastric  contents. 

Common  Symptoms. — The  most  noteworthy  symptom  in  this  condition 
is  vomiting  or  regurgitation.  Said  vomiting  will  follow  soon  after  food 
reaches  the  stomach.  In  some  cases  all  of  the  food  partaken  will  be 
ejected ;  in  other  cases  small^  quantities  will  be  vomited  at  intervals.  On 
placing  the  infant  in  the  dorsal  position  antiperistaltic  waves  can  be  noted 
by  inspecting  the  abdomen.  These  waves  are  seen  after  food  is  taken. 
These  worm-like  movements  disappear  when  the  stomach  is  empty.  From 
the  loss  of  food  and  improper  nutrition  there  naturally  results  loss  of 
weight.  When  the  spasm  yields,  the  food  will  pass  into  the  duodenum,  and 
resulting  therefrom  there  will  be  more  or  less  fseces  evident.  If,  therefore, 
stool  is  noted,  then  spasm  of  the  pylorus  and  not  stenosis  exists. 

Pyloric  Stenosis. — When  an  obstruction  due  to  a  pyloric  hypertrophy 
and  stenosis  exists,  there  results  usually  a  dilatation  of  the  stomach  from 
the  stagnation  of  the  gastric  contents.  The  evacuations  following  colonic 
flushing  will  bring  away  some  jellj^-like  or  greenish  masses,  but  milk 
fasces  will  not  be  found.  This  is  an  important  diagnostic  point  and  will 
differentiate  the  spasmodic  from  the  stenosed  condition. 

In  suspected  or  congenital  pyloric  stenosis  JSTobecourt^  and  Merklin 
have  shown  that  normal  children,  3  months  old,  will,  by  giving  0.015 
giamme  of  carmine,  in  three  to  nine  hours  pass  a  red  stool.  Therefore,  the 
retention  of  carmine  must  prove  an  anatomical  obstruction  somewhere  in 
the  digestive  tract. 

Diagnostic  Aid. — A  small  metallic  bucket,  devised  by  Einhorn,  some- 
what smaller  than  an  ordinary  sized  pea,  is  fastened  to  a  white  silk  cord. 

This  bucket  is  introduced  into  the  stomach  by  placing  it  on  the  tongue 
and  feeding  the  infant  a  bottle  of  water  or  food.    The  infant  swallows  the 

^NohCcourt  und  Merklin,  Bull.  d.  la  Soc.  d.  Pediatrie.     12.  I.  1910. 


PYLORIC  OBSTRUCTION. 


225 


bucket  and  the  same  is  allowed  to  remain  in  the  stomach  over  night.  When 
pyloric  ptcnosis  is  present  the  bucket  remains  in  the  stomach.  If,  however, 
there  is  no  stenosis  the  bucket  will  pass  into  the  duodenum,  and  the  bile- 
stained  string  will  show  the  probable  depth  that  the  bucket  entered  the 
duodenum. 

I  choose  the  evening  feeding  time  or  about  G  p.m.  as  the  best  time  for 
introducing  the  bucket,  then  give  the  infant  the  regular  feeding,  and  with 
very  few  exceptions  the  same  was  retained.  If,  however,  the  bucket  was 
expelled  by  vomiting  it  was  reintroduced  at  the  next  feeding.  To  be  sure 
that  no  obstruction  to  the  duodenum  existed,  I  left  the  bucket  in  over 


Fig.  58. — Infantile  Duodenal  Bucket  with  Syringe  attached,  to  Aspirate  Bile. 

night.  On  withdrawing  the  same  after  about  twelve  hours,  a  yellowish 
bile-stain  from  the  duodenal  bucket  for  at  least  8  to  10  centimeters  will  be 
noted  on  the  cord.    In  pyloric  obstruction,  however,  no  hile-stain  was  noted. 

By  this  method  of  diagnosis  we  can  learn  whether  or  no  pyloric 
stenosis  is  present.     It  is  an  important  aid  if  surgical  relief  is  demanded. 

Instead  of  a  cord,  a  thin  rubber  tubing  attached  to  and' ending  in  a 
perforated  bucket  can  be  passed  into  the  stomach,  and  by  leaving  it  there 
several  hours  the  bucket  will  pass  through  into  the  duodenun\.  By  means 
of  a  little  glass  syringe,  I  was  enabled  to  aspirate  bile,  in  some  cases  a 
greenish,  in  other  cases  a  yellowish  fluid,  alkaline  in  reaction  and  of 
viscid  consistency. 

There  are  three  ferments  for  which  a  test  can  be  made.  They  are:  (a) 
steapsin.  (h)  trypsin,  (c)  amylopsin. 

(a)  To  test  for  trypsin,  I  use  1  drop  of  neutral  milk.  '^  drops  of  water, 
2  or  3  drops  of  duodenal  contents  (neutralized  if  the  reaction  is  acid),  and 
a  small  piece  of  blue  litmus  agar.  This  is  placed  into  a  miniature  test 
tube  and  kept  at  blood  temperature.  If  steapsin  is  present  the  agar  will  be 
red  in  twenty  to  thirty  minutes,  owing  to  the  development  of  fatty  acids. 


226  DISEASES  OF  THE  STOMACH. 

(h)  For  the  demonstration  of  trypsin  I  nse  a  small  piece  of  the  white 
of  a  hard-boiled  egg,  which  is  placed  in  the  fluid  to  be  examined  (if  acid,  it 
is  first  neutralized)  and  kept  a  few  hours  at  blood  temperature.  The  piece 
of  egg  albumin  disappears  in  the  presence  of  trypsin.  The  ricin  test  used 
for  pepsin  is  unsuitable  for  trypsin.  If  we  add  ricin  solution  to  duodenal 
contents  and  leave  it  at  blood  temperature  for  a  few  hours,  and  then  add 
hydrochloric  acid  or  acetic  acid,  the  ricin  will  often  be  precipitated,  i.e.,  it 
will  not  be  changed  into  soluble  peptone. 

(c)  Amylopsin.  In  testing  for  the  presence  of  diastase  we  make  use 
of  a  boiled  starch  solution  or  starch  paper.  We  mix  the  duodenal  contents 
with  the  starch  solution  (in  equal  parts),  or  insert  a  strip  of  starch  test 
paper  and  leave  it  at  blood  temperature  for  one-half  to  one  hour,  adding  a 
weak  solution  of  iodine.  Starch,  if  present,  gives  a  blue  color,  and  erythro- 
dextrin  a  red  color ;  otherwise  only  a  trace  of  brown  from  the  iodine. 

Hypertkophic  Pyloric  Stenosis. 

This  condition  is  not  so  rare  in  infancy  -as  is  commonly  supposed. 
While  in  1902  Cautley  and  Dent  reported  109  cases,  we  have  since  then 
over  150  cases  recorded  in  medical  literature. 

Etiolo^. — Stenosis  may  occur  as  a  congenital  malformation.  Hyper- 
acidity is  believed  to  be  responsible  for  some  cases  of  spasm  of  the  pylorus 
resulting  in  hypertrophy.  Thomson  believes  that  by  the  ingestion  of  liquor 
amnii  in  intra-uterine  life  both  the  stomach  and  pylorus  are  excited  to  over- 
action,  due  to  the  presence  of  this  irritant  fluid. 

Morbid  Anatomy. — ^Under  normal  conditions  the  circular  muscle  fibers 
of  the  pylorus  at  birth  are  relatively  augmented,  gradually  approaching  the 
normal  as  the  long  axis  of  the  stomach  assumes  its  horizontal  direction  from 
the  vertical ;  this  relative  augmentation  of  the  circular  fibers  is  intended 
to  prevent  the  too  rapid  emptying  of  the  vertical  tubular  infantile  stomach 
during  the  first  two  weeks  of  life.  These  fibers,  stimulated  to  excessive 
function  by  any  given  cause,  must,  according  to  recognized  physiological 
principles,  become  hypeitrophied. 

Accepting  such  a  working  basis,  we  should  recognize  in  hypertrophic 
pyloric  stenosis  the  ultimate  results  of  a  pathological  process  whose  first 
stage  is  represented  l)y  an  excessive  functional  activity  of  the  pyloric  muscu- 
lature ;  its  second  stage  by  hypertrophy  and  spasm  of  this  musculature,  and 
the  third  stage  Ijy  a  general  overgrowth  of  the  normal  constituents  of  the 
involved  parts. 

Symptoms. — There  is  a  sudden  onset  of  sj^mptoms.  The  food  will 
suddenly  disagree.  There  are  active  peristaltic  and  antiperistaltic  waves 
visible.  This  is  most  marked  after  the  infant  has  swalloAved  food  or  water. 
In  a  case  reported  l^y  me  very  strong  peristaltic  Avaves  could  be  noticed 


HYPERTROPHIC  PYLORIC  STENOSIS.  227 

from  left  to  riglit.^  There  was  a  distinct  hourglass  contraction,  the  stoniacli 
bulging  on  either  side  with  a  sulcus  in  the  middle.  The  abdominal  walls 
are  lax.  The  intestinal  wall,  chiefly  the  transverse  colon,  can  be  easily 
mapped  out. 

On  palpating  the  pylorus  in  my  own  case,  a  hard,  resisting  mass  about 
the  size  of  an  adult's  thumb  could  be  felt.  Gradual  emaciation  from  inani- 
tion will  be  noted. 

Stagnation  of  the  gastric  contents  is  proven  by  the  fact  that,  while 
two  ounces  of  the  food  are  swallowed,  six  or  eight  ounces  are  frequently 
regurgitated  and  vomited.  The  quantity  of  urine  is  also  scant,  owing  to  the 
small  quantity  of  liquid  and  food  absorbed.  A  whole  day  will  frequently 
pass  without  a  single  diaper  being  wet. 

The  examination  of  the  gastric  contents  shows  great  variability.  In 
my  own  case,  the  presence  of  lactic  acid  and  the  total  absence  of  hydro- 
chloric acid  were  noted.  Other  observers  have  noted  an  excess  of  h3'dro- 
chloric  acid. 

Prognosis. — If  the  vomiting  persists,  death  will  occur  from  exhaustion. 
In  a  case  seen  by  me,  where  operation  was  refused,  the  infant  died  of  inani- 
tion after  three  weeks. 

Treatment. — Dilute  the  food  to  half-strength.  If  a  milk  mixture  con- 
taining 3  per  cent,  of  fat  has  been  given,  then  1  per  cent,  should  be  tried. 

There  should  be  a  longer  interval  between  the  feedings.  If  a  baby 
has  been  fed  every  two  hours,  it  should  be  fed  once  in  three  hours.  If  two 
ounces  had  been  given  at  one  feeding,  then  one  ounce  should  be  tried.  If, 
after  this  method,  vomiting  persists,  then  the  stomach  should  be  allowed  to 
rest  at  least  twenty-four  hours,  during  which  time  rectal  feeding  can  be 
tried.  Stomach-washing  every  morning  with  normal  saline  solution  may  do 
good  in  some  cases. 

On  the  theory  that  hyperacidity  caused  pyloric  spasm,  Knoepfelmacher 
used  whole  milk  feedings  to  modify  the  hyperacidity.  Bromide  of  sodium, 
codeine,  menthol,  or  subnitrate  of  bismuth  may  be  tried. 

Surgical  Treatment. — If,  after  a  patient  trial  of  the  above-outlined 
plan,  the  condition  does  not  improve,  then  surgical  relief  is  indicated.  In 
this  stenotic  stage,  gastro-duodenostomy  in  two  sittings,  if  necessary,  should 
be  the  operation  of  choice. 

"At  the  first  of  these,  slight  fixation  of  the  involved  parts  to  the  abdomi- 
nal incision,  opening  of  the  duodenum,  and  the  insertion  of  a  temporary 
catheter  for  purposes  of  direct  feeding. 

"After  a  proper  interval,  depending  upon  the  patient's  gain  in  nutrition 
and  strength,  an  anastomosis  between  this  opening  in  the  duodenum  and 
the  stomach,  either  by  the  small  button  of  ]\Ieyer  or  a  modification  of  the 
Finney  operation."     (Sturmdorf.) 


1  Archives  of  Pediatrics,  May,   1906. 


228  DISEASES  OF  THE  STOMACH. 

Post-operative  Treatment. — Strychnine,  ^/loo  grain  hj^podemiically 
every  three  hours,  is  required.  Normal  saline  injections,  either  by  high 
colonic  flushing,  or,  if  the  jjulse  is  weak,  by  means  of  hypodermoclysis. 

By  mouth,  several  teaspoonfuls  of  whey  every  hour.  This  method  is 
ample  for  the  first  few  days,  after  which  special  feeding  rules  may  be  in- 
dicated. 

Gastro-duodejStitis   (Cataeehal  Jaundice). 

When  the  infection  of  an  acute  catarrhal  gastritis  extends  into  the  duo- 
denum, jaundice  usually  results.  This  is  due  to  an  involvement  of  the 
common  bile  ducts. 

Symptoms  and  Diagnosis. — Yellowish  pigmentation  of  the' skin  and  con- 
junctival mucous  membrane  are  noted.  The  urine  is  brown  or  deep  yellow. 
The  stool  is  whitish  or  clay-colored.  The  temperature  ranges  between 
100°  and  103°' F.  Anorexia  and  thirst  usually  exist.  Nausea  or  vomiting 
may  occur.    The  pulse  is  full  and  regular.    The  liver  is  usually  enlarged. 

Treatment. — ^Elaterine  or  podophyllin,  V20  to  Vio  grain,  repeated,  if 
necessary,  in  three  hours,  or  phosphate  of  soda,  10-  to  20-  grain  doses  every 
three  hours  until  liquid  stools  are  produced.  Dilute  nitro-muriatic  acid, 
2  to  5  drops,  may  be  given  twice  a  day.  Liquid  food,  such  as  thin  soups, 
diluted  milk  or  skim-milk  or  buttermilk,  and  fruit  juices,  for  thirst. 

Cheonic  Gasteitis  (Cheonic  Glandular  Gastritis — Chronic 

Vomiting)  . 

This  is  a  chronic  inflammatory  disease  affecting  the  gastric  mucous 
membrane.  The  functions  of  the  stomach  are  disturbed  owing  to  the  large 
quantities  of  alkaline  mucus  being  secreted.  There  is  a  distinct  loss  of 
tone  in  the  gastric  mucosa.  Large  quantities  of  food  will  frequently  stag- 
nate, causing  fermentation  and  vomiting. 

Pathology. — The  changes  in  chronic  gastritis,  seen  post-mortem,  are 
similar  to  those  met  with  in  the  acute  form.  There  is  a  degeneration  of  the 
epithelium  of  the  gastric  tubules.  Frequently  there  is  dilatation  of  the 
stomach. 

Microscopically  the  glands  often  seem  enlarged,  sacculated,  and  dilated 
in  cyst-like  fonns.  Ewald  states  that  there  is  a  mucoid  degeneration. 
When  there  is  a  total  destruction  of  the  glandular  layer  of  the  entire  organ, 
we  have  an  atrophic  condition  Avhich  Ewald  calls  auadenia  ventriculi. 

Symptoms. — Vomiting  is  a  prominent  symptom.  Large  quantities  of 
sour  or  bile-stained  mucus  are  ejected.  At  other  times  sour-smelling  liquid 
containing  particles  of  food  is  ejected.  Farinaceous  foods  cause  particular 
distress.  Pains  referred  to  the  abdomen  are  complained  of,  and  the  abdo- 
men is  usually  distended  and  tender  on  palpation.      The  tongue  is  coated. 


CHRONIC  GASTRITIS.  229 

The  papillae  are  enlarged  and  the  edges  and  tip  are  or  a  hright  glazed  red. 
Eructations  of  gas  are  frequently  noted,  especially  after  feeding. 

llie  Boivels. — Constipation  alternates  with  diarrhcea  in  this  condition. 
We  find  a  child  will  suffer  with  constipation  for  three  or  four  days,  and  for 
no  apparent  reason  a  diarrhoea  will  appear  and  continue  for  a  week  or 
more.  Eczema  is  usually  associated  with  tliis  condition.  There  is  usually 
anorexia.  Owing  to  the  malnutrition,  such  children  appear  underfed  and 
seem  to  be  anannic.  They  emaciate  from  loss  of  sleep  in  addition  to  the 
continued  vomiting.  Their  extremities  are  usually  cold,  owing  to  a  poor 
circulation.  Headache  is  a  prominent  symptom  in  children  old  enough  to 
complain.  The  clinical  picture  is  such  that  one  must  take  extreme  care 
to  make  a  proper  diagnosis.  Frequently  there  is  a  hacking  cough  present. 
We  may  exclude  tuberculosis  if  the  pulmonary  signs  are  wanting  in  addi- 
tion to  the  absence  of  the  tubercle  bacillus. 

Diagnosis. — The  diagnosis  is  easily  made  if  we  remember  that  tuber- 
culosis has  fever  which  at  times  assumes  a  hectic  form.  We  have  previously 
mentioned  the  necessity  of  finding  the  tubercle  bacillus  if  tuberculosis  is 
suspected.  Typhoid  fever  is  so  different  that  we  can  easily  exclude  this  by 
resorting  to  the  Widal  and  diazo  reactions.  Syphilis,  if  suspected,  will 
respond  to  specific  treatment. 

Prognosis  and  Course. — This  condition  should  be  looked  upon  as  every 
other  chronic  disease  in  which  vitality,  surroundings,  and  proper  care  play 
an  important  part.  If  a  child  of  a  poor  family  living  in  a  tenement  house 
suffers  with  this  chronic  disease,  the  outcome  will  be  different  than  if  the 
child  were  living  in  the  country,  where  fresh  air  could  and  would  stimulate 
metabolism.  Earely  is  this  condition  fatal,  although  with  extreme  emacia- 
tion and  continued  vomiting  inanition  may  cause  death. 

Treatment. — Dietetic  Treatment:  This  is  the  most  important  factor. 
The  feeding  interval  should  be  extended  so  that  the  child  should  be  fed 
less  often  than  formerly.  The  quantity  of  food  should  be  reduced  so  that 
the  stomach  receives  less  work.  By  all  means  give  food  that  is  easily  as- 
similated. In  some  cases  nothing  but  predigested  food  or  peptonized  milk 
will  be  retained.  Each  child  should  receive  a  carefully  prepared  diet  list, 
and  we  must  insist  on  strict  rules.  Give  older  children  soups,  broths,  albu- 
min, such  as  white  of  egg,  and  peptonized  yolk  of  egg.  Give  infants  diluted 
milk  or  one  of  the  infant  foods  temporarily.  When  vomiting  persists  and 
apparently  little  or  no  food  is  retained,  it  is  advisable  to  put  the  child  to 
bed  and  resort  to  rectal  feeding  for  two  or  tnree  days.  This  is  one  of 
the  best  means  of  allaying  gastric  irritability.  (See  chapter  on  "Eectal 
Feeding.") 

Hygiene.- — Without  fresh  air,  active  exercise,  such  as  walking,  or 
passive  movements,  such  as  massage  or  gymnastics,  we  must  expect  little 
or  no  benefit.  Daily  sponging  or  bathing,  followed  by  friction  with  a  coarse 
towel,  will  stimulate  the  circulation. 


330 


DISEASES  OF  THE  STOMACH. 


Medication. — Stomach  washing,  by  using  1  or  2  pints  of  warm  water 
to  which  bicarbonate  of  soda  has  been  added,  is  ver}^  useful.  This  may  be 
repeated  every  day.  Sodium  phosphate,  in  5-  to  10-  grain  doses,  every  morn- 
ing or  evening,  is  indicated. 

Fowler's  solution,  in  1-  to  5-  drop  doses,  three  times  a  day,  and  nux 
vomica,  in  1-minim  doses,  three  times  a  day.^ 

Bismuth  subnitrate  or  bismuth  beta-naphthol,  to  relieve  the  diarrhoea, 
are  very  valuable  remedies. 

For  persistent  vomiting  menthol,  in  l-grain  doses,  and  oxalate  of 
cerium,  in  2-  or  3-  grain  doses,  every  few  hours,  are  useful.  Gentle  currents 
of  faradic  electricity  will  also  aid  and  strengthen  the  atonic  condition. 

Acute  Dilatation  of  the  Stomach. 

This  condition  is  quite  frequently  met  with  in  children. 
Etiology. — The  anatomical  and  physiological  peculiarities  of  the  in- 
fantile stomach  render  it  peculiarly  susceptible  to  the  development  of  this 


DILATED  STOMACH, 
At  age  of  one  month. 


Fig.  59. — Drawing  from  a  Case  of  Acute  Dilatation  of  the  Stomach, 
Giving  Exact  Size  Post-mortem.  Bottle-fed  Infant.  Summer  Complaint, 
Due  to  Over-feeding,  and  Too  Frequent  Feeding.  Compare  normal  size  with 
the  dilated  condition.      (Original.) 


^  Frasor,   of   Xew   York   City,   makes   a    1-minim   nux   vomica    tablet,    which    is 
soluble  and  quite  palatable. 


BULIMIA.  231 

condition.  The  walls  of  the  stomach  are  thin.  The  weakness  of  the  re- 
sistance of  the  muscular  walls  and  tiie  ease  .with  which  a  general  anaimia 
and  resultant  muscular  atony  occur  in  children  must  be  remembered  in 
considering  etiological  factors.  IJachitis  plays  an  important  part  in  the 
development  of  this  condition.  Severe  gastric  catarrh  with  associated 
fermentative  conditions  are  predisposing  factors. 

Pathology. — A  general  atrophied  condition  of  the  entire  gastric  wall 
exists.  The  muscular  coats  are  frequently  thickened.  The  mucous  mem- 
brane shows  evidences  of  chronic  catarrh.  This  condition  is  usually  seen 
in  marasmic  or  rachitic  children.    The  stomach  is  invariably  dilated. 

The  symptoms  of  this  condition  correspond  to  those  of  chronic  gastric 
catarrh.  In  standing  the  child  upright  the  contour  of  the  greater  curvature 
of  the  stomach  can  be  made  out  if  emaciation  exists.  Vomiting  is  a  promi- 
nent symptom,  a  sour,  frothy  liquid  being  thrown  up.  Succussion  is  fre- 
quently heard,  but  cannot  be  depended  on  as  a  positive  symptom  in  this 
condition.  Children  suffering  with  acute  dilatation  usually  have  a  very 
good  appetite.  They  always  show  evidences  of  malnutrition.  The  results 
of  percussion  are  very  misleading.  A  tympanitic  sound  may  be  heard  when 
the  child  is  on  its  back.  It  may  also  be  absent.  Henoch  states  that  severe 
dilatation  of  the  stomach  in  a  child  may  cause  dyspnoea.  It  may  also  dis- 
place the  heart  if  dilatation  is  severe. 

Eiagnosis. — The  diagnosis  can  usually  be  made  by  the  symptoms  above 
described.  It  is  important  to  remember  that  a  dilatation  of  the  colon  may 
exist  at  the  same  time ;  if  so  the  differentiation  between  dilatation  of  the 
colon  and  dilatation  of  the  stomach  can  be  made  by  artificially  distending 
the  stomach  with  the  aid  of  a  Seidlitz  powder.  Translumination  of  the 
stomach  with  the  aid  of  a  gastrodiaphane  will  aid  in  mapping  out  the 
anatomical  outlines  of  the  stomach. 

Prognosis. — This  depends  on  the  condition  of  the  child  when  treat- 
ment is  commenced.  If  the  child  is  physically  debilitated  and  does  not 
assimilate  food,  the  prognosis  is  gTave.  It  is  safest  to  give  a  cautious 
prognosis  in  every  case. 

Treatment. — Semi-solid  foods  should  be  given,  if  possible,  and  large 
quantities  of  liquids  avoided.  The  normal  tone  of  the  stomach  can  best  be 
restored  by  the  administration  of  nux  vomica  and  iron  in  suitable  doses. 
The  value  of  electricity  and  massage  must  be  remembered.  They  will 
restore  tlie  tone  of  the  stomach  when  judiciously  used.  Specific  conditions 
such  as  rickets  and  syphilis,  if  present,  require  their  proper  treatment. 


Bulimia  (ABXomiAL  ArrExiTi:). 

Constant  desire  to  eat  is  frequently  seen  when  intestinal  parasites,  such 
as  tapeworm,  are  present.     It  is  also  found  as  a  symptom  of  hysteria. 


232 


DISEASES  OF  THE  STOMACH. 


A.  B.,  7  years  old,  desired  five  and  six  meals  a  day.  Her  body  was  emaciated 
and  occasional  abdominal  pains  were  described.  The  mother  attributed  the  pains  to 
overeating.  After  several  doses  of  filix  mas  a  tapeworm  Avas  dislodged  (see  treat- 
ment in  the  chapter  on  "Tapeworm")   and  the  bulimia  disappeared. 

Gastroptosis    (Descensus  Venteiculi)^  Low  Position  of 
THE  Stomach. 

We  are  indebted  to  Glenard^  for  emphasizing  sufficiently  the  clinical 
symptoms  due  to  this  condition. 

Etiology. — In  subnormal  conditions  such  as  chlorosis  or  where  a  gen- 
eral atony  exists,  a  weakening  of  the  ligaments  takes  place  and  the  abdom- 


Fig.  60. — Translumination  of  the  Stomach  with  the  Aid  of  a  Gastro- 
diaphane,  in  a  Case  of  Gastroptosis.      (Original.) 

inal  viscera  consequently  descends.  Very  tight  lacing  is  frequently  a  cause 
in  3^oung  girls. 

In  a  series  of  autopsies  made  by  Glenard  he  found  the  transverse  colon 
displaced  and  stenosed.- 

Symptoms, — A  variety  of  nervous  symptoms  such  as  irritability,  head- 
ache, restlessness  by  day  and  insomnia  by  night,  is  frequently  due  to  this 
disorder.  The  S}miptoms  which  characterize  nervous  dyspepsia  in  the  adult 
correspond  with  the  train  of  symptoms  noted  in  this  condition.  Constipa- 
tion is  usually  present ;   there  are  loss  of  appetite  and  eructations. 


*Lyon  mCdicale,   1885,  p.  450. 

''Einhorn:     "Diseases  of  the  Stomach,"     First  Edition,  p.  368. 


GASTROPTOSIS. 


233 


Diagnosis. — Ewald  advises  inllation  of  the  stomach  as  the  best  means 
of  (lia<,nH)sis.  "When  the  stomach  is  inflated  the  lesser  curvature,  in  cases 
of  gastroptosis,  is  visible  midway  between  the  ensiform  process  and  the 
navel,  or  just  in  the  neighborhood  of  the  umbilicus."'  With  the  aid  of  the 
gastrodiaphane  we  can  transluminate  the  stomach  and  make  out  the  contour 
of  the  same.  This  has  been  found  a  valuable  means  of  diagnosis.  The  red 
illuminated  area  can  be  plainly  made  out  if  the  room  is  darkened.  The 
following  case  illustrates  this  condition  as  met  with  in  practice: — 

Rosie  B.  was  first  seen  by  me  when  13  years  old. 

Family  History. — Father  and  mother  living  and  well.  She  has  six  sisters  and 
one  brother  living,  all  in  good  health.  There  is  no  family  history  of  syphilis,  rheuma- 
tism, or  tubercailosis.     One  child  of  3  years  died  from  pneumonia  complicating  measles. 

Personal  History. — She  was  a  breast-fed  child  and  appeared  to  be  well  de- 
veloped. She  has  had  measles  and  with  it  bronchitis.  .Menstruation  appeared  when 
she  was  13  years  old  and  lasted  seven  days.  She  has  complained  for  the  last  two 
a        .  b 


Fig.   61. —  (a)    Normal  Position  of  Stomach.      (6)   Position  of  Stoiiiaoh  in  a 
Case  of  Gastroptosis.      (Original.) 

years  of  headaches,  pains  in  the  back  and  abdomen,  loss  of  appetite,  and  does  not 
sleep  well.  She  is  very  nervous  and  lias  had  a  peculiar  unilateral  twitching  in- 
volving the  right  arm  and  shoulder.  This  twitching  appears  spasmodically  and  is 
exaggerated  when  her  attention  is  directed  to  it.  She  complains  of  cold  extremi- 
ties, and  has  an  occasional  cough.  No  expectoration.  The  cough  appears  to  be 
of  the  same  character  as  tliat  seen  in  adults  which  is  described  as  a  hysterical  cough. 
The  chemical  examination'^  of  the  gastric  contents  syphoned  off  one  hour  after 
feeding  a  test  meal  of  tea  and  zwieback  gave  the  following:  25  cubic  centimeters 
obtained,  color  greenish  yellow,  very  tenacious,  ptyalin  present  in  saliva.  Reaction 
of  gastric  juice  acid,  no  free  hydrochloric  present,  lactic  acid  absent,  peptones 
present,  sugar  present,  starch  present,  combined  hydrochloric  acid  present,  estimated 
by  titration  equals  0.02  per  cent,  hydrochloric  acid.  A  splashing  s-ound  could  be  made 
out  on  the  left  side  of  the  abdomen  in  the  area  bounded  by  the  umbilicus  or  above 
it  to  the  symphysis  pubis.  With  the  aid  of  the  gastrodiaphane  the  outline  of  the 
stomach  could  be  plainly  seen  extending  below  the  umbilicus.  In  the  accompany- 
ing illustration   (Fig.  61)  the  position  of  the  stomach  is  outline,!. 

^I  am  indebted  to  Mr.  LaWall,  clicmist,  for  this  analysis. 


234  DISEASES   OF   THE   STOMACH. 

Prognosis  and  Course. — A  displaced  organ  is  not  easily  replaced  by- 
giving  drugs  or  by  mechanical  treatment.  The  physician  should  inform 
the  patient's  relatives  regarding  the  true  condition.  The  life  of  the  child 
is  not  necessarily  endangered  by  the  displaced  stomach,  yet  the  abnormality 
should  be  treated  on  the  principle  of  general  building  up  of  the  entire  sys- 
tem with  special  reference  to  the  diet. 

Treatment. — The  treatment  of  these  cases  consists  in  building  up  the 
system  with  the  aid  of  electricity,  massage,  and  general  restorative  treat- 
ment; cold  sponging  with  brisk  friction  of  the  surface  of  the  body  to 
stimulate  the  circulation;  also,  light  bodily  gymnastics.  Nux  vomica  or 
its  alkaloid,  strychnine,  should  be  given  for  a  long  time. 

A  tight-fitting  abdominal  bandage  has  frequently  relieved  acute  symp- 
toms. Boas,  of  Berlin;  Einhorn,  Kemp,  and  Eose,  of  New  York,  are 
among  those  who  advocate  supporting  the  abdominal  muscles  by  this 
mechanical  device. 

Surgical  Treatment. — When  no  relief  is  obtained  by  the  abdominal 
supporter  or  bandage  previously  referred  to,  then  surgery  may  be  demanded. 
Some  surgeons  advise  supporting  the  stomach  by  means  of  stitching  the 
omentum  to  the  abdominal  peritoneum.  By  this  means  we  have  "a  method 
of  suspending  the  stomach  in  a  hammock  made  by  the  great  omentum." 

Ulcee  of  the  Stomach. 

Gastric  ulcer  is  frequently  seen  in  chlorotic  girls.  It  is  usually  the 
result  of  living  in  unsanitary  surroundings,  or  when  the  body  is  reduced 
to  a  subnormal  condition.  Young  girls  at  or  about  the  period  of  menstrua- 
tion that  are  sent  to  work  in  factories  or  shops,  who  cannot  take  proper 
time  for  their  meals,  are  occasionally  seen  with  evidences  of  gastric  ulcer. 
In  most  cases  the  ulcer  is  simply  a  continuation  of  a  chronic  catarrh  of  the 
gastric  mucous  membrane  which  has  laid  the  foundation  for  this  condition. 

Symptoms. — -Pain  in  the  stomach,  which  is  distinctly  localized  and  can 
be  pointed  to  in  the  same  area.  The  pain  increases  after  taking  solid  food, 
although  pain  is  also  noted  when  any  liquid  enters  the  stomach.  At  times 
bright-red  blood  will  be  expectorated,  although  the  blood  may  be  very  dark 
in  color.  There  is  also  a  tender  area,  usually  localized  between  the  ninth 
and  tenth  dorsal  vertebras,  which  is  marked  on  palpation. 

Diagnosis. — ^The  positive  diagnosis  should  only  be  made  after  a  chem- 
ical examination  of  the  gastric  contents  is  made.  The  test  meal  and  the 
method  of  examination  are  described  in  Part  XII,  Chapter  II,  to  which  the 
reader  is  referred.  If  an  excess  of  HCl  is  found  in  addition  to  the  sub- 
jective symptoms  of  pain,  the  diagnosis  of  gastric  ulcer  is  positive. 

The  following  case  of  gastric  ulcer  was  presented  by  me  before  the 
New  York  County  Medical  Association,  May  15,  1899 : — 


CYCLIC  VOMITING.  235 

Mary  B.,  l.'i  years  old,  complained  of  headaclies  and  general  weakness.  She 
was  emaciated  and  had  anorexia.  She  had  suffered  with  constipation,  dizziness, 
nausea,  and  vomiting.  Her  heart's  action  was  irregular.  For  four  years  she 
coniphiined  of  pain  in  the  middle  of  the  stomach  which  was  always  localized  in 
the  same  area.  The  gastric  pains  were  strongest  aft«r  partaking  of  solid  food. 
She  had  pain  whenever  any  food,  solid  or  liquid,  was  swallowed.  The  pain  is 
described  as  a  burning  pain.  She  has  a  tender  area  between  the  ninth  and  tenth 
dorsal  vertebra3.  This  tenderness  is  marked  on  palpation.  Three  years  ago  she 
had  an  attack  of  hsematemesis,  but  none  since  then.  The  gastric  contents  were 
examined  after  a  test  meal,  and  an  excess  of  HCl  was  found.  Owing  to  the 
danger  of  traumatism  I  thouglit  it  best  not  to  repeat  the  syphoning  off  of  the 
gastric  contents,  as  there  was  a  risk  in  repeating  the  haemorrhage.  There  was  no 
evidence  of  hysteria  in  the  case.     The  diagnosis  of  gastric  ulcer  was  made. 

Treatment. — Liquid  diet,  rest  in  bed,  and  bismuth  gave  quite  some  relief. 
When  solid  food  was  tried  the  gastric  pain  returned. 

Prognosis  and  Course. — Great  care  should  be  taken  before  giving  a 
positive  opinion  concerning  the  outcome  of  gastric  ulcer.  If  the  condi- 
tions that  induced  the  disease  can  be  modified,  then  a  chance  for  recover}' 
exists.  These  cases,  as  a  rule,  do  badly  unless  placed  under  the  strictest 
supervision  of  a  trained  nurse.  Such  cases  require  treatment  in  bed,  rather 
than  ambulant  treatment.  Years  of  patient  treatment  may  be  required 
before  positive  benefit  is  secured. 

The  prognosis  depends  on  the  above  conditions.  The  disease  is  chronic 
and  may  cause  death. 

Treatment. — Such  cases  do  well  by  having  a  change  of  air.  These 
children  should  not  be  permitted  to  attend  school,  and  the  same  applies  to 
the  workshop,  if  the  child  is  working.  Sea  bathing  and  cold  sponging  of 
the  body,  followed  by  friction,  is  very  beneficial.  A  rigid  liquid  diet,  con- 
sisting of  peptonized  milk,  zoolak,  soup,  broth,  and  strained  gruel,  with  an 
occasional  change  to  cocoa,  should  be  allowed.  Fruit  may  also  be  pennitted. 
This  treatment  must  usually  be  carried  out  for  months  before  recovery  may 
be  expected. 

Cyclic  Vomiting. 

A  great  many  writers  report  attacks  of  vomiting  occurring  at  irregular 
or  regular  intervals  of  weeks  or  months  which  are  termed  cyclic  vomiting. 
They  claim  that  these  attacks  are  not  dependent  on  acute  gastric  disturb- 
ances, but  are  simply  explosions  due  to  latent  or  possibly  nervous  conditions. 
As  a  rule,  we  have  such  attacks  in  cases  of  acidosis.  ]\[ore  often  these  attacks 
of  so-called  c^'clic  vomiting  are  associated  Avith  recurrent  attacks  of  appen- 
dicitis. A  blood  examination  should  be  made  (see  article  on  "Appendi- 
citis"), so  that  we  can  exclude  appendicitis  as  a  cause  of  the  cyclic  vomiting. 
(See  article  on  the  "Significance  of  Vomiting,"  page  71.) 


236 


DISEASES  OF  THE  STOMACH. 


Dyspeptic  Asthma. 


Peripheral  irritation  of  the  terminal  filaments  of  the  pneumogastric 
nerve  frequently  causes  dyspeptic  symptoms,  which  result  in  asthmatic 
attacks  similar  to  those  found  in  adults.  A  case  of  this  kind  came  under, 
my  care  in  which  fermentative  conditions  in  the  stomach  caused  pressure 
on  the  diaphragm  and  gave  rise  to  asthmatic  attacks. 

A  well-nourished  boy,  9  years  old,  was  referred  to  me  by  Dr.  H.  Jarecky.  He 
had  attacks  of  coughing,  wheezing,  and  slight  cyanosis.  The  hands  and  feet  were 
cold.  The  tongue  was  coated;  the  stomach  distended  with  gas  and  very  tympanitic 
on  percussion.  The  asthmatic  attacks  were  caused  by  the  distention  and  pressure 
on  the  diaphragm,  and  disappeared  when  a  rigid  diet  and  a  laxative  were  given. 
The  boy  suffered  in  addition  with  rheumatism. 


CHAPTER  IV. 

DISEASES  OF  THE  INTESTINES. 

Infant  Stools. 

Meconium. — The  first  discharge  from  an  infanfs  bowels  is  called 
meconium.  It  has  a  greenish-brown  color;  at  times  it  resembles  ink  in 
color.  It  is  composed  of  epithelial  cells,  bile,  cholesterin  crystals,  and 
partly  digested  amniotic  fluid.  Meconium  has  no  odor.  It  is  usually  acid  in 
reaction.  The  color  of  the  infant's  stool  changes  after  a  few  days  of  ma- 
ternal or  bottle  feeding. 

As  soon  as  the  exclusive  milk  diet  is  changed  to  the  mixed  diet  we  then 
lose  the  characteristic  infantile  stool,  and  it  resembles  more  that  of  an  adult, 
though  remaining  softer  and  thinner  throughout  infancy.  The  stools  be- 
come darker  in  color,  assume  the  adult  odor,  and  have  more  varieties  of 
bacteria  than  those  previously  mentioned  as  found  in  the  stool  of  a  milk 
diet. 

A  new  conception  of  the  various  food  elements  shows  that  the  opinion 
of  ten  years  ago  regarding  the  dangers  of  high  fat  has  been  modified,  and 
the  possibility  of  a  protein  or  casein  element  being  the  disturbing  factor 
suggested.  Modern  science  has  proven  beyond  a  doubt  that  one  reason  why 
the  fat  element  or  casein  disagrees  is  due  to  the  presence  of  milk  sugar; 
hence  we  today  regard  the  cwhohydrate  and  salt  as  the  disturbing  element 
in  many  cases,  rather  than  the  fat  or  casein. 

Finkelstein,  of  Berlin,  has  proven  that  in  atrophic  and  marasmic 
infants  in  which  there  is  a  constant  decomposition  associated  with  fever  and 
undigested  stools  we  can  modify  the  nutrition  and  restore  faulty  metabolism 
by  omitting  the  addition  of  sugar  or  salt.  The  most  important  point, 
however,  is  that  we  can  feed  a  very  large  fat  and  protein  food,  such  as  casein 
milk,  described  in  the  chapter  on  Faulty  Metabolism,  without  causing 
gastric  disturbance. 

The  stool  of  a  nursling  or  an  infant  on  a  human  breast  should  be 
yellowish  in  color,  smeary  or  pasty-like  in  consistency,  and  have  an  acid 
reaction.  Normal  yellow  stool  of  a  breast-fed  infant  contains  bilirubin. 
Hydrobilirubin  is  associated  with  bilirubin  after  several  weeks. 

Not  infrequently  during  the  first  three  months,  normal  infants  fed 
exclusively  at  the  human  breast  will  have  several  stools  a  day.  They  may 
be  green,  watery,  contain  mucus,  or  appear  lumpy.  Such  infants  thrive, 
gain  in  weight,  sleep  well,  and  are  apparently  healthy.  The  cause  of  such 
peculiar  stool  has  not  yet  been  determined.  They  may  be  caused  by 
maternal  influences.  Such  stools  are  more  frequent  whilst  the  mother  is 
menstruating.     These  stools  should  by  no  means  be  regarded  as  due  to  a 

(237) 


338  DISEASES  OF  THE  INTESTINES. 

pathological  condition,  for  we  all  can  notice  how  this  condition  will 
regulate  itself;  even  though  greenish  stools  persist  for  several  weeks,  by  no 
means  should  we  change  the  food,  but  continue  the  breast  if  at  all  possible 
for  the  first  three  months. 

In  no  branch  of  pediatrics  has  so  much  progress  been  made  in  recent 
years  as  in  the  study  and  interpretation  of  infant  faeces.  The  more  we  study 
infantile  metabolism,  the  more  we  find  that  an  intimate  relationship  be- 
tween internal  secretions,  on  the  one  hand,  and  properly  modified  food,  on 
the  other  hand,  must  exist. 

Modern  views  concerning  the  nature  of  curds  in  the  stool  have  de- 
cidedly changed  since  the  studies  of  Czerny  and  Keller.  What  formerly  was 
believed  to  be  casein  curds  is  now  proven  by  chemical  analysis  to  consist 
principally  of  fat,  but  there  are  large,  tough  curds  which  are  composed  of 
casein  in  which  fat  is  intermingled.  The  small,  soft  curds,  however,  some  of 
them  lentil-shaped  or  resembling  round  or  flattened  particles  of  compressed 
butter,  consist  chiefly  of  fatty  acids  and  calcium  soap  in  addition  to  a  low 
percentage  of  protein. 

Talbot  describes  a  simple  test  which  will  easily  differentiate  a  casein 
curd  from  a  fat  cnrd,  by  placing  the  supposed  curd  in  a  10  per  cent,  for- 
malin and  allowing  it  to  stand  from  four  to  six  hours.  If  casein  the  curd  will 
harden ;  if  fat  it  will  become  soft. 

Langstein,^  speaking  of  the  white  fseces,  regards  the  same  as  due  to  a 
faulty  assimilation  and  signifies  the  beginning  of  a  disturbance  of  metab- 
olism. Thus,  such  white  fseces  may  be  due  to  a  deficiency  of  the  biliary 
S'ecretion,  but  there  also  may  be  a  disturbance  in  the  intestine.  Czerny  and 
Keller  regard  the  cause  of  the  white  fseces  as  due  to  the  presence  of  calcium 
soap. 

Jaffe,  Gerhardt,  and  Zoja  in  a  series  of  examinations  have  shown  that, 
when  urobilin  and  bilirubin  are  absent,  the  derivatives  of  the  bile-pigments, 
such  as  urobilinogen,  may  be  present.  This  latter  substance  is  a  reduction 
product  of  urobilin.  Urobilinogen  is  constantly  noted  in  alkaline  solutions, 
but  is  transformed  into  urobilin  in  an  acid  solution. 

Normal  and  healthy  children,  such  as  those  fed  on  human  milk,  give  a 
negative  urobilinogen  reaction  in  the  urine.  On  the  other  hand,  artificially 
fed  infants  give  a  strong  urobilinogen  reaction  in  the  urine.  The  reaction 
is  very  strong  in  cases  of  occlusion  of  the  common  bile-ducts,  so  that  this 
reaction  is  of  great  service  in  the  differentiation  of  duodenal  catarrh  in 
infancy. 

One  of  the  reasons  for  the  presence  of  the  large  curds  is  the  absence  of 
hydrochloric  acid,  which  acid  when  entering  the  duodenum  stimulates  the 
flow  of  pancreatic  juice. ^ 


^Langstein:     Salkowsky's  Festschrift,  1904. 
''Fisher:    "Physiology  of  Alimentation,"   1907. 


STOOLS.  239 

Reaction  of  Stools. — Eeaction  of  stools  in  diarrhoeal  disease  and  in 
health  is  chiefly  acid,  or,  next  in  frequency,  neutral.  Alkaline  stools  are 
rare.  Grass-green  stools,  usually  acid,  are  seen  in  the  early  stage  of 
dyspeptic  diarrhoea.  The  color  varies  from  a  pale  greenish  yellow  to  grass 
green,  owing  to  improper  food. 

The  reaction  depends  on  the  presence  of  lactic  acid,  the  source  of  which 
is  the  milk  sugar.  The  only  gases  present  are  H  and  CO,.  According  to 
Escherich,  HoS  and  CH4,  to  which  the  odor  of  adult  -stool  is  due,  are  not 
present.  There  are  no  special  albuminoids  peculiar  to  woman's  milk. 
Those  existing  in  woman's  milk  seem  to  be  entirely  absorbed.  Peptone 
exists  in  trifling  amount.  Sugar  is  not  present.  Pancreatic  ferment  is 
absent,  and  sometimes  traces  of  pepsin  have  been  found.  Mucus  is  always 
present  in  considerable  quantity;  also  columnar  intestinal  epithelium. 

In  the  stool  of  nurslings  large  quantities  of  lactate  of  lime  can  be 
found;  so  also  we  frequently  find  oxalate  of  lime,  depending  on  the  quan- 
tity of  oxalate  of  lime  ingested.  Ufflemann  has  noted  the  presence  of 
bilirubin  crystals  in  the  stools  of  nurslings  in  perfect  health. 

Quantity  of  Faeces. — ^The  quantity  of  fgeces  varies,  but  it  has  been 
found  that  100  grams  of  milk  food  will  produce  about  3  grams  of  faeces, 
according  to  Baginsky,  This  is  a  vital  point,  but  I  have  found  it  very 
difficult  to  determine,  for  in  most  cases  the  napkins  of  the  infant  are 
soiled  with  urine  plus  the  faeces,  thus  adding  to  the  gross  weight. 

Green  Stools. — The  green  color  of  stool  is  caused  by  an  abnormal 
oxidation  of  bile-pigment  in  which  bilirubin  is  changed  into  biliverdin  by 
means  of  an  oxidase. 

Typical  green  stools  can  be  produced  by  giving  an  infant  two  or  three 
grains  of  bicarbonate  of  soda;  the  soda  must  be  given  for  a  few  days.  This 
explains  Pfeiffer's  alkaline  theory.  Typical  green  stools  can  also  be  pro- 
duced by  giving  small  or  large  doses  of  calomel.  If,  after  having  given 
bicarbonate  of  soda  and  produced  green  stools,  we  give  diluted  hydrochloric 
acid  in  5-  to  10-  drop  doses,  the  yellow  color  will  reappear  in  a  few  days. 
Rhubarb  will  also  produce  a  yellow  stool. 

Stools  which  are  pale  yellow  when  discharged,  and  which  afterward 
become  green,  are  often  seen  in  disease.  They  may  be  themselves  neutral 
or  alkaline  in  reaction;  this  latter  may,  however,  depend  on  the  admixture 
of  urine.    An  excess  of  bile  may  often  cause  very  green  stools. 

Wegscheider  has  shown  that  the  green  color  is  the  result  of  preformed 
biliverdin.  The  condition  in  the  intestine,  upon  which  the  transformation 
of  bilirubin  into  biliverdin  depends,  has  been  generally  regarded  as  one  of 
acid  fermentation. 

Pfeiffer's  experiments^  show  this  former  opinion  to  be  wrong.     He 


^  "Verdauung   im    Siluglings-alter   bei    Krankhaften-Ziistanden,"    Jahrbuch    fiir 
Kinderheilkunde,  B.  28,  page  164. 


240  DISEASES  OF  THE  INTESTINES. 

found  that  none  of  the  acids  formed  in  such  fermentation — lactic,  acetic, 
butyric,  propionic,  etc. — added  to  j^ellow  stools  outside  the  body  turned 
them  green,  but  that  they  made  them  deeper  yellow.  But  dilute  alkaline 
solutions  added  to  fresh  yellow  stools  turned  them  green  after  an  exposure 
of  thirty  to  sixty  minutes,  and  strong  solutions  turned  them,  first,  brown; 
later,  after  exposure  to  air,  intense  green. 

Casein  in  high  and  low  percentages  has  decided  therapeutic  properties. 
It  increases  the  intestinal  secretion  which  amounts  to  about  one  quart 
daily.  It  has  an  alkaline  reaction;  hence  acts  antagonistic  to  pathological 
acidity  and  thereby  arrests  fermentation.  It  is  possible  therefore  to  modify 
intestinal  fermentation  associated  with  putrefactive  stools  by  omitting 
sugar  and  salt,  reducing  the  fat,  but  chiefly  by  increasing  the  casein. 

When  milk  sugar  is  added  in  large  quantities  to  food,  it  results  in  a 
primary  irritation  of  the  epithelium  of  the  intestine,  resulting  in  acid 
fermentation,  and  this  latter  prevents  new  epithelium  from  forming.  When 
this  carbohydrate  element  (milk  sugar)  is  reduced  the  symptoms  are 
immediately  modified,  and  when  the  milk  sugar  is  discontinued  the  casein 
lumps  quickly  disappear  from  the  stool;  in  addition  thereto  the  stool 
assumes  a  more  solid  consistency. 

Casein  Masses  or  White  Curds. — The  coarser  lumps  of  casein  or  so- 
called  casein  curds  will  be  described  later  on.  The  small  casein  curds 
consist  chiefly  of  fat.  Casein  is  not  nearly  as  common  an  ingredient  of 
fgeces  as  is  supposed.  As  far  back  as  1878  Widerhofer  doubted  that  these 
masses  were  really  casein,  but  believed  them  to  be  fat  with  epithelial 
remains.  Adler  maintains  that  it  is  wrong  to  call  a  substance  casein  be- 
cause it  responds  to  heat,  biuret.  Heller,  and  other  protein  reactions. 

Casein  masses  or  casein  lumps  are  frequently  found  in  infants  whose 
intestinal  tract  had  been  thoroughly  emptied,  and  where  the  diet  consisted 
of  whey.  It  is  well  known  tliat  the  casein  masses  consist  chiefly  of 
undigested  remains  of  casein  together  with  fatty  acids  and  alkalies  (Seller). 
The  nucleoproteins  of  the  intestinal  secretion  and  the  nucleo albumins  of 
the  bile  give  a  similar  reaction.  When  milk  has  been  withheld  for  a 
number  of  days  watery  discharges  in  enterocolitis  will  also  give  a  positive 
protein  reaction  in  the  stool,  due  to  casein  masses.  The  principle  of  butter- 
milk feeding  lies  in  the  transformation  of  the  casein  into  casein  lactate. 

When  milk  is  deprived  of  fat  and  casein,'  the  result  is  whey,  and  if 
this  whey  is  fed  to  an  infant  we  frequently  have  casein  curds  in  the  stool. 
These  curds  consist  of  saponified  fats  and  numerous  bacteria.  The  protein 
reaction  does  not  come  from  casein,  but  from  the  intestinal  secretion, 
whereas  the  fatty  acids  and  saponified  fats  are  due  to  the  sugar  in  the 
whey. 

Intestinal  experiments  at  Finkelstein's  clinic,  reported  by  Meyer  and 
Leopold,  show  that  when  the  food  contains  a  higher  percentage  of  sugar 


STOOLS.  241 

than  the  infant  can  assimilate  the  result  will  be  so-called  casein  masses  in 
the  stool.  That  this  view  is  correct  is  proven  by  the  fact  that  the  moment 
the  sugar  element  is  reduced  casein  particles  gradually  disappear.  This 
fact  will  be  still  more  impressed  when  we  note  that  with  the  reduction  of 
the  sugar  we  can  increase  the  percentage  of  casein,  thus  showing  a  higher 
tolerance  for  casein,  after  we  reduce  the  carbohydrate  element. 

Protein. — The  protein  of  milk  is  so  thoroughly  absorbed  that  only 
small  traces  of  it  can  be  found  in  the  ffeces. 

Albuminous  decomposition  and  its  products — tyrosin,  indol,  phenol, 
and  skatol — are  not  found  in  milk  fooces.  Lactic  acid,  acetic  acid,  formic 
acid,  and  other  fatty  acids  are  present,  causing  the  acid  reaction. 
Von  Jaksch  found  a  saccharine  ferment  in  the  faeces  of  children.  Baginsky 
found  a  peptonizing  ferment  also  in  infantile  faeces.  Escherich^  says :  "If 
albmninous  decomposition  with  very  foul  offensive  stools  exists,  albumins 
should,  be  withheld  from  the  diet  and  carbohydrates,  such  as  dextrine  foods, 
sugar,  and  milk,  given.  If  acid  fermentation  is  present  with  sour,  but  not 
offensive  stools,  carbohydrates  are  to  be  withheld  and  an  albuminous  food 
such  as  animal  broths,  bouillon,  peptones,  etc.,  given.  In  the  decomposition 
of  milk,  the  sugar  of  milk,  and  not  the  casein,  is  usually  broken  up.'' 

Sugar. — If  the  sugar  is  too  low,  the  gain  in  weight  is  apt  to  be  slower 
than  when  furnished  in  proper  amount.  The  symptoms  indicating  an 
excess  of  sugar  are :  colic  or  thin,  green,  very  acid  stools,  sometimes  causing 
irritation  of  the  buttocks;  sometimes  there  is  regurgitation  of  food  and 
eructations  of  gas. 

Artificially  fed  children  excrete  hydrobilirubin  constantly.  Whitish 
stools  are  usually  associated  with  atony,  also  with  various  types  of  mild 
dyspepsia.  In  dyspeptic  stools  we  are  apt  to  find  undigested  casein  or 
saponified  fats.  Scrambled  egg  stools  frequently  contain  particles  of  undi- 
gested casein  and  fat. 

Fat  Diarrhoea. — This  condition  is  primarily  due  to  an  imperfect  func- 
tion of  the  bile  as  well  as  to  the  abnormal  state  of  the  pancreatic  secretion. 
In  such  conditions  as  tuberculosis  of  the  mesenteric  glands  and  in  severe 
enteric  catarrh  we  are  apt  to  find  very  fatty  stools.  According  to  Biedert 
and  Demme,  who  have  devoted  considerable  study  to  this  subject,  in  some 
children  the  faeces  showed  50  to  60  per  cent,  of  fat,  whereas  the  normal 
percentage  in  ordinary  fgeces  varied  from  14  to  25  per  cent,  (which  is  the 
normal  quantity,  according  to  Ufflemann) . 

Excess  of  fat  is  indicated  by  the  frequent  regurgitation  of  food  in 
small  quantities,  usually  one  or  two  hours  after  feeding.  Sometimes  an 
excess  of  fat  causes  very  frequent  stool  nearly  normal  in  appearance.    In 


^Jahrbuch   flir   Kinderlieilkunde,   "Beitriige   zur   Antiseptisclien    Beliandlungs- 
methode  der  Magen-Darmkrankheiten  des  Sauglingsalters." 

16 


342  DISEASES  OF  THE  INTESTINES. 

some  cases  the  stools  contain  small,  round  lumps  someAvhat  resembling 
casein,  but  really  masses  of  fat. 

Blood  in  Stools.- — Blood  from  the  stomach  or  small  intestine  frequently 
gives  the  stool  a  black  color  resembling  tar.  Thus,  a  practical  point  in 
Boasts  "Diagnostik  der  Magen-  und  Darmkrankheiten"  is  that,  the  brighter 
the  color  of  the  blood,  the  lower  down  near  the  rectum  and  anus  must  the 
pathological  lesion  be  looked  for;  the  darker  the  blood,  the  higher  up  must 
the  cause  be  sought;  e.g.,  the  diseased  condition  exists  in  the  stomach, 
duodenum,  or  jejunum,  etc.,  if  the  stool  contains  black  blood.  If  the 
corpuscular  elements  of  the  blood  are  wanting,  then  only  the  presence  of 
blood  can  be  positively  diagnosticated  by  either  a  microchemical  examina- 
tion or  by  means  of  the  spectroscope.  The  presence  of  red  blood-corpuscles 
must  always  be  regarded  as  a  pathological  factor. 

Brown  Stools,  Muddy  Stools. — A  brown  stool  in  an  infant  is  frequently 
caused  by  a  diet  of  animal  food  or  by  a  diet  principally  of  broth.  These 
stools  have  no  distinct  consistency  nor  reaction.  In  dyspeptic  diarrhoea  or 
in  some  forms  of  enterocolitis  we  have  very  offensive  stools  and  they 
resemble  muddy  water;  with  the  latter  there  is  considerable  flatus  during 
each  movement. 

Brown  stools  may  be  due  to  changed  biliary  pigment  and  to  drugs : 
e.g.,  bismuth  causes  the  well-known  dark  stool.  So  also  tannic  acid  and 
all  iron  salts  give  the  dark  stool,  which  varies  from  a  deep  brown  to  a 
black  color. 

Mucus. — Mucus  is  always  present  in  all  healthy  stools  and  is  so  well 
mixed  with  the  stool  that  it  does  not  appear  as  mucus  to  the  naked  eye. 
Any  appearance,  therefore,  of  mucus  easily  visible  should  be  regarded  as 
abnormal.  Mucus  is  present  in  every  form  of  intestinal  disease:  very 
abundant  in  inflammatory  conditions  affecting  the  large  intestine,  more  so 
than  in  those  affections  of  the  small  intestine,  and  especially  so  in  inflam- 
matory conditions  of  the  colon,  both  acute  and  chronic. 

Jelly-like  masses  or  shreds  of  mucus,  and  cases  where  the  stool  con- 
sists chiefly  of  mucus,  show  that  the  affection  is  confined  to  the  lower 
portion  of  the  colon  or  that  it  is  located  in  the  rectum. 

Long  shreds  of  mucus,  frequently  resembling  false  membrane,  are 
often  found  in  catarrh  of  the  large  intestine.  If  the  shreds  of  mucus  are 
intimately  mixed  with  the  stool,  then  we  must  look  for  the  lesion  quite  high 
up,  and  if  it  comes  from  the  small  intestine  it  is  usually  stained  from  bile. 
If  the  lesion  is  low  down  the  mucus  is  not  intimately  mingled  with  the 
stool. 

White  or  Light-gray  Stools. — These  stools  usually  are  of  a  putty-like 
consistency,  sometimes  like  dry  balls  on  a  diaper;  sometimes  they  appear 
like  ashes.  Usually  they  are  very  offensive,  consisting  principally  of  fat. 
There  is  scarcely  a  trace  of  bile,  or  the  latter  may  be  absent  altogether. 


BACTERIA  OF  THE  INTESTINES. 


243 


Scybalous  Stools. — These  are  hard,  dry,  usually  round  masses  in  which 
the  intestinal  lubricant  is  absent.  These  stools  are  usually  accompanied  by 
flatulence.  From  their  stagnation  in  the  colon  the  gas  bacteria  cause  a 
chronic  distention  and  enlargement  of  the  abdomen. 

Dyspeptic  Stool, — The  first  change  noticed  in  the  dyspeptic  stool  is  the 
increase  of  fat.  Often  the  stool  is  quite  green  and  contains  small  pieces, 
of  yellowish-white  color,  which  vary  in  size  from  that  of  a  pinhead  to  the 
size  of  an  ordinary  pea.  Hitherto,  from  their  color,  they  were  supposed  to 
be  casein  lumps.  Wegscheider  has  taught  us  that  they  consist  principally 
of  fat.     Baginsky  has  shown  that  large  colonies  of  bacteria  are  contained 


Fio:.  62. — Bacterium   Coli   Commune. 


in  these  lumps  of  fat.  Frequently  they  are  so  numerous  that  it  looks  as 
though  the  stool  were  composed  only  of  these  cheesy  lumps.  They  can  be 
easily  differentiated  from  real  casein  lumps  by  their  solubility  in  alcohol 
and  ether. 

Bacteria  of  the  Intestines. 

There  are  a  great  many  bacteria  found  in  the  intestines.  These  are 
present  in  a  normal  infant,  as  well  as  in  an  infant  suffering  from  a  gastro- 
intestinal disorder.  A  great  many  of  these  bacteria  are,  therefore,  non- 
pathogenic. Miller,  who  carefully  studied  the  various  micro-organisms  in 
the  mouth,  found  that  most  of  them  could  again  be  found  in  the  intestinal 
canal. 

Moro  describes  the  bacillus  acidophilus,  which  is  a  constant  inhabitant 
in  both  the  small  and  large  intestine.  It  has  the  property  of  coagulating 
cows'  milk,  but  not  human  milk.    The  bacillus  bifidus  communis  will  chiefly 


244 


DISEASES  OF  THE  INTESTINES. 


be  found  in  the  intestine  of  a  breast-fed  infant.  It  is  anaerobic.  The  bac- 
terium coli  communis  and  bacterium  lactis  aerogenes  are  largely  concerned 
in  the  formation  of  lactic  acid.  The  colon  bacillus  generates  indol  as  well. 
The  role  played  by  bacteria  is  not  yet  well  understood.  It  is  quite  possible 
that,  instead  of  doing  harm,  some  bacteria  do  good.  This  is  especially 
noted  when  all  bacteria  are  destroyed  by  sterilization,  and  bacteria-free  milk 
is  fed.     Such  prolonged  feeding  may  result  in  scurvy. 

DlARRHCEA.^ 

By  diarrhoea  is  meant  too  frequent  stools.     This  increased  peristalsis 
is  usually  due  to  some  specific  cause.     Infants  on  a  liquid  diet  are  more 


Fig.  63. — Bacterium  Lactis  Aerogenes. 

prone  to  loose  evacuations  than  older  children  on  a  solid  or  semi-solid  diet. 
Children  suffering  from  rickets  or  atrophy  infantum,  or  any  form  of  mal- 
nutrition, are  more  prone  to  the  development  of  diarrhoea.  The  cause  of 
the  bulk  of  the  cases  of  diarrhoea  seen  by  me  during  the  last  fifteen  years, 
in  one  of  the  largest  dispensaries  of  New  York  City,  was  bottle-feeding. 
Out  of  1000  cases  of  diarrhoea  900  were  bottle-fed  and  lived  amid„poor 
hygienic  surroundings.  In  90  cases  the  children  were  breast-fed,  but  there 
was  a  disturbance  during  lactation.  This  disturbance  was  pregnancy, 
menstruation,  tuberculosis,  or  syphilis  in  the  mother,  or  prolonged  nursing 
with  deficient  fats  and  protein. 

In  10  cases  there  was  no  assignable  cause  excepting  the  subnormal  con- 
dition of  the  body  due  to  an  excess  of  midsummer  heat. 


See  also  chapter  on  "Intoxication." 


DIARRHCEA.  245 

Contaminated  Milk. — Impurities^  such  as  bacteria,  filth,  and  chemical 
products  due  to  fermentation,  can  easily  cause  diarrhoea.  In  my  article  on 
'TBacteria  in  the  Intestine,"  I  describe  the  two  most  frequent  varieties  of 
bacteria  which  are  normally  found  in  the  intestine.  They  are  the  bac- 
terium coli  and  the  bacterium  lactis.  These  bacteria  frequently  assume  a 
virulent  form  under  certain  conditions.  They  very  often  cause  diarrhoea. 
Other  bacteria,  such  as  the  streptococci,  can  be  introduced  in  cows'  milk. 
A  diseased  udder  in  the  cow  will  frequently  secrete  pus  in  addition  to  milJc. 
Such  milk  must  necessarily  cause  trouble  when  introduced  into  the  in- 
fantile stomach  or  bowels. 

Improper  Diet  for  Older  Children. — We  frequently  see  people  who 
think  it  wise  to  give  their  children,  regardless  of  their  age,  a  bit  of  any- 
thing from  the  table.  Eaw  fruits  and  raw  vegetables,  cabbage,  and  pickles 
are  given  regardless  of  the  consequences.  In  studying  the  dietetic  sins  com- 
mitted by  the  parents  of  children  in  two  dispensaries  located  in  different 
sections  of  New  York  City,  I  found  the  following  conditions : — 

One  hundred  children  between  the  second  and  sixth  years  of  age 
living  in  tenements  apparently  healthy;  80  received  a  taste  of  beer  or  a 
drop  of  whisky  diluted  with  water  every  day.  In  some  families  the  children 
received  as  much  as  a  wineglassful  and  more  of  beer  with  each  meal.  Such 
imprudence  is  frequently  a  distinct  factor  in  the  causation  of  diarrhoea. 

Nervous  Diarrhoea. — The  influence  of  fright  or  excitement  is  the  best 
example  of  diarrhoea  due  to  nervous  influence  that  can  be  given.  When 
caused  by  a  nervous  influence  the  fseces  contain  mucus,  and  there  is  usually 
an  explosive  stool.  It  is  a  form  of  exaggerated  peristalsis.  Chilling  the 
surface  of  the  body  frequently  provokes  diarrhoea. 

Diarrhoea  as  a  Symptom  of  Disease. — Nature's  method  of  eliminating 
poison  is  frequently  seen  when  a  diarrhoea  commences  in  the  course  of  an 
acute  infectious  disease.  Toxic  products  can  best  be  eliminated  by  the 
emunctories,  and  the  intestines  are  one  of  the  most  valuable  agents  for 
eliminating  poison  from  the  body.  The  diarrhoea  of  typhoid  fever,  sum- 
mer complaint,  dysentery,  and  ileo-colitis  have  been  described  in  their 
respective  chapters. 

Treatment. — Seek  the  cause  and  if  possible  remove  the  same.  If  a 
dietetic  error  has  caused  the  diarrhoea,  then  a  good  dose  of  castor-oil  should 
be  ^iven.  In  all  events  a  good  cleansing  should  begin  the  treatment.  Mist, 
rhei  et  sodte  in  teaspoonful  doses  can  be  given  several  times  to  cleanse  the 
gastro-intestinal  tract.  Several  hours  after  the  laxative  has  been  given  the 
rectum  and  colon  should  be  flushed  with  hot  water  containing  a  teaspoonful 
of  salt  to  each  pint.  The  temperature  of  the  saline  solution  should  be  about 
110°  F. 

Bismuth  in  3  to  10-grain  doses,  repeated  every  two  hours,  is  our  best 
remedy. 


246  DISEASES  OF  THE  INTESTINES. 

IJ  Mist,  creta 2  ounces, 

one  teaspoonful  every  two  hours,  is  also  valuable. 

Diet. — Stop  all  milk.  Give  whey  and  rice  water  thickened  with  potato 
flour  or  wheat  flour.  Give  the  white  of  egg  several  times  a  day ;  also  cocoa 
and  water. 

For  Thirst. — Give  5  to  10  drops  of  diluted  hydrochloric  acid  in  a  tum- 
blerful of  boiled  water  (sterilized).    This  can  be  given  ad  lihitum. 

Diluted  phosphoric  acid,  2.0  drops  to  a  tumblerful  of  sweetened  water, 
is  a  pleasant  drink  during  fever.    It  is  also  stimulating. 

The  charts  on  pages  247,  248,  and  249  were  kindly  furnished  to  me 
by  Dr.  William  H.  Guilfoy,  Chief  of  the  Bureau  of  Statistics,  Health  De- 
partment, City  of  New  York, 

Insolation  (Heat-stroke;  Sunstroke). 

This  condition  is  most  frequently  seen  in  midsummer.  It  sometimes 
occurs  in  perfectly  healthy  children  who  are  exposed  to  the  direct  rays  of 
the  midday  sun.  I  have  frequently  seen  cases  of  sunstroke  in  feeble  cfiil- 
dren  who  were  playing  in  the  shade.  Children  with  lowered  vitality  and 
convalescents  from  some  severe  illness,  such  g,s  diphtheria  or  pneumonia, 
are  more  prone  to  be  affected  by  intense  summer  heat. 

Pathology. — Intense  cerebral  hypersemia  and  an  intense  engorgement 
of  the  veins  throughout  the  body  are  the  usual  lesions  seen  in  this  con- 
dition. 

Symptoms. — A  child  in  apparently  good  health  in  midsummer  will 
suddenly  show  intense  fever.  The  temperature  reaches  as  high  as  104° 
or  105°  P.  in  many  instances.  There  is  a  corresponding  increase  in  the 
pulse-rate.  The  pulse  may  be  as  high  as  160  or  180.  The  face  is  usually 
flushed.  The  head  is  hot.  There  is  a  throbbing  of  the  blood-vessels  very 
apparent.  The  child  may  be  unconscious  and  muscular  twitchings  may  be 
noticed.     In  severe  prostration  there  may  be  delirium  and  convulsions. 

The  pupils  are  usually  contracted,  although  they  may  be  dilated,  and 
the  eyes  intensely  congested.  Sometmies  vomiting  and  diarrhoea  may  ac- 
company the  symptoms  above  mentioned. 

The  following  illustrates  the  manner  in  which  heat-stroke  occurs  in 
New  York  City : — 

A  child  will  awaken  in  a  normal  condition,  eat  its  breakfast  and  play  as  usual. 
After  several  hours'  hard  playing  and  exposure  to  the  sun's  rays,  the  child  will  be 
exhausted.  If  a  careless  mother  or  nurse  permits  the  child  to  continue  its  exposure 
to  the  direct  midsummer  heat,  then  prostration  with  the  above-noted  symptoms  will 
be  noticed.  In  some  cases  brought  to  my  clinic,  the  head  is  hot  and  the  hands  and 
feet  are  cold.  If  the  sunstroke  takes  place  soon  after  feeding,  then  violent  gastric 
symptoms  usually  occur. 


DIARRHCEA. 


248 


DISEASES  OF  THE  INTESTINES. 


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250 


DISEASES  OF  THE  INTESTINES. 


Prognosis. — The  prognosis  depends  upon  the  vitality  at  the  time  of 
simstroke.  We  must  differentiate  this  condition  from  meningitis.  The 
suddenness  of  the  attack  following  exposure  to  the  sun  will  usually  aid 
in  making  a  diagnosis.  The  majority  of  cases  seen  by  me  recovered.  Occa- 
sionally a  fatal  case  was  encountered,  especially  in  bottle-fed  infants. 


Fig.  67. — Insolation   (Heat-stroke).     Type  of  midsummer  cases  in  New 
York  City.     (Original.) 

This  infant  (Fig.  67),  brought  to  my  clinic  July,  1909,  weighed  5  pounds  6 
ounces.  He  was  a  bottle-fed  infant,  reared  on  condensed  milk.  He  was  nine  weeks 
old.  Vomited  after  each  feeding,  had  greenish,  mucous,  sour-smelling  stools,  every 
half-hour  and  oftener.  There  was  eczema  between  the  thighs  from  excoriation  and 
acid  stools.    The  child  weighed  6^/^  pounds  at  birth,  and  was  a  full-term  baby. 

The  child  was  pulseless.  The  extremities  were  cold  and  covered  with  a  clammy 
perspiration.  The  temperature  was  subnormal — 97°  F.  The  fontanel  was  de- 
pressed. The  heart  sounds  were  barely  audible.  The  mouth,  tongue,  and  lips  were 
very  dry;  food  and  water  were  refused.  Spirits  of  camphor,  5  drops,  was  injected 
hypodermically ;  a  mustard  foot-bath  was  ordered.  The  child  died  fifteen  minutes 
later. 


DYSENTERY.  251 

Diagnosis. — Cholera  infantum,  marasmus,  due  to  malassirailation  of  food;  im- 
proper food  to  commence  with.  Extreme  heat  caused  heart-failure  and  general  pros- 
tration. 

Treatment. — A  tub-bath,  temperature  90°  F.,  gradually  decreased  to 
70°  F.,  duration  five  minutes,  is  advisable.  An  ice-bag  should  be  applied 
to  the  head.  If  consciousness  has  been  restored,  the  child  should  be  al- 
lowed to  rest;  if  not,  then  we  can  restore  the  circulation  to  relieve  cerebral 
hypergemia  by  giving  a  mustard  foot-bath  for  several  minutes  until  the  skin 
is  reddened.  The  rectum  and  colon  should  be  flushed  with  a  hot  saline 
solution  at  a  temperature  of  110°  F. ;  thi's  will  stimulate  diuresis  besides 
cleansing  the  bowel.  One-drop  doses  of  aromatic  spirits  of  ammonia  with 
water  may  be  given  every  fifteen  minutes. 

If  the  child  can  swallow  then : — 

IJ  Bromide  of  sodium   10  grains 

Chloral  hydrate   3  grains 

should  be  given  to  a  child  5  years  old.  This  can  be  repeated  every  hour 
until  a  sedative  effect  is  produced.  In  some  cases  (comatose)  it  may  be 
advisable  to  inject  per  rectum : — 

IJ  Bromide  of  sodium   15  grains 

Starch  water    1  ounce 

Cold  water  should  be  given  by  mouth,  with  several  drops  of  diluted 
hydrochloric  acid.  Peptonized  milk,  thin  soups,  and  broths  may  be  given 
every  few  hours.    Liquid  peptonoids  can  be  tried  if  food  is  rejected. 

Dysentery  (Ileo-colitis). 

The  lower  portion  of  the  intestine  is  frequently  the  seat  of  an  infection 
by  pathogenic  bacteria. 

Pathology. — As  this  condition  frequently  follows  severe  milk  infection, 
the  pathogenic  lesions  are  necessarily  the  same,  although  in  a  more  ag- 
gravated form.  In  addition  to  the  hypersemia  of  the  mucous  membrane 
there  may  be  a  small  haemorrhage  in  the  mucosa  or  submucosa.  The  mucous 
membrane  is  very  deeply  pigmented,  frequently  being  of  a  purplish  line. 
The  solitary  lymph  follicles  along  the  colon  are  swollen.  The  discharge  of 
mucus  is  tinged  with  blood,  and  not  infrequently  the  amoeba  coli  described 
by  Lbsch,  or  known  as  the  amoeba  dysenteries,  described  by  Councilman  and 
Lafleur,  can  be  found.  "It  is  a  unicellular,  protoplasmic,  motile  organism 
from  10  to  20  micro-millimeters  in  diameter,  and  consists  of  a  clear  outer 
zone  (ectosarc)  and  a  granular  inner  zone  (endosarc),  containing  a  nucleus 
and  one  or  more  vacuoles."  Multiple  abscesses  are  frequently  found.  "The 
ulcer  first  begins  as  a  small  papule,  the  upper  part  of  which  sloughs  off, 
leaving  a  grayish-yellow  ulcerating  surface." 


252 


DISEASES  OF  THE  INTESTINES. 


Diphtheritic  dysentery,  sometimes  known  as  the  croupous  variety,  is 
a  catarrhal  form  of  this  same  condition  previously  described,  in  which  the 
infection  can  be  traced  to  an  invasion  of  the  Klebs-Loeffler  bacillus.  The 
ulcerations  are  covered  with  a  pseudo-membrane,  and  the  pathogenic  con- 
ditions are  as  previously  described. 

Bacteriology.^ — There  are  two  groups  of  bacilli  which  are  responsible 
for  the  development  of  various  types  of  epidemic  dysentery: — • 

1.  The  true  Shiga  group. 

2.  Group  of  mannite  fermenters. 

The  latter  group  is  divided  into  two  types : — 


f'\::r- 


..  '\^^; 


r-'Si- 


^>^, 


Wl. 


•^ 


Fig.  68. — Bacillary  Diphtheria  of  the  Colon  or  Diphtheritic  Colitis,  a. 
Necrotic  tissue  containing  bacilli.  6,  Gland  with  necrotic  epithelium,  d, 
Connective  tissue,  e,  Degenerated  and  exfoliated  epithelial  cells,  f,  Bacilli 
in  the  lumen  of  the  gland,  g,  Bacillary  deposit  beneath  the  epithelium. 
7i,  Nests  of  bacilli  in  the  connective  tissue.    X300.     (Ziegler.) 


(a)   Fermenting  mannite  alone  in  peptone  solution. 

(h)   Fermenting  maltose  and  saccharose. 

Symptoms.— The  attack  is  usually  ushered  in  with  diarrhoea.  There 
is  also  considerable  straining  with  each  stool.  At  first  the  stools  contain 
particles  of  faeces,  and  as  the  disease  progresses  they  become  more  liquid 
and  contain  mucus  and  blood.  Some  authors  describe  the  stool  as  con- 
taining shreds  that  resemble  the  washings  of  raw  meat.  The  face  shows 
a  very  anxious  expression.  There  is  extreme  pallor.  The  child  appears 
prostrated.  The  pulse  is  accelerated  and  very  feeble.  The  abdomen  is 
distended,  especially  over  the  colon.  Vomiting  is  a  rare  symptom.  Unless 
treatment  is  rapidly  instituted  the  child  will  fail  in  strength  and  may  die. 


^  The  Journal  of  Medical  Research,  a^oI.  xi,  No.  2,  May,   1904. 


DYSENTERY. 


253 


Such  children  usually  sleep  with  the  eyes  hall:  open  and  show  evidences 
of  collapse.  The  rectum  may  protrude,  especially  when  there  is  a  distinct 
relaxation  of  these  parts.  Cold,  clammy  perspiration  is  usually  found, 
especially  on  the  head.  The  extremities  are  cold.  Convulsions  appear  in 
the  severer  forms  of  dysentery.  In  the  diphtheritic  variety  the  temperature 
and  pulse  resemble  a  case  of  true  diphtheria.  The  stool,  in  addition  to 
mucus  and  blood,  may  have  particles  of  pseudo-membrane.  Toxemia  can 
usually  be  seen  by  its  effect  on  the  heart  and  pulse.  The  urine  may  contain 
albumin.  Where  the  toxasmia  progresses,  convulsions  may  set  in  and  death 
result  from  cardiac  paralysis. 


Fig.  69. 


■^Croupous  Enteritis,  Diphtheritic  Colitis,  two-tliirds 
natural  size.      (Langerhans.) 


Diagnosis. — The  bloody  mucus  and  watery  stools  seen  in  this  con- 
dition, associated  with  tenesmus,  will  usually  aid  in  eliminating  acute 
milk  infection.  In  gastro-enteritis  and  entero-colitis  there  is  usually  a 
greenish,  spinach-like  stool,  or  a  brown,  muddy  stool  having  a  very  foetid 
odor.  The  stools  in  dysentery  are  smaller  in  quantity.  Both  the  diph- 
theritic and  the  amoebic  forms  of  dysentery  are  rare  in  children. 

Prognosis.i — If  this  disease  is  epidemic,  or  if  it  occurs  in  children 
having  bad  sanitary  surroundings,  then  the  prognosis  is  bad.  The  dura- 
tion of  an  acute  attack  is  usually  about  five  or  six  days.  The  prognosis 
is  good  when  the  diarrhoea  and  blood  gradually  disappear.  The  main 
point  to  remember  is  that  the  heart  must  be  sustained  by  proper  nutrition, 
and  we  should  try  to  coimteract  the  toxaemia  by  proper  stimulation. 


254  DISEASES  OF  THE  INTESTINES. 

Treatment. — ^The  same  hygienic  measures  described  in  the  chapter  on 
"Food  Intoxication"  apply  equally  as  well  here.  Impress  the  mother 
or  nurse  that  unless  she  carries  out  the  directions  minutely,  the  child  has 
little  chance  of  recovery. 

Dietetic  Treatment. — The  dietetic  management  will  consist  in  leaving 
out  milk.  Whey,  barley  water,  rice  water,  or  toast  water  may  be  given. 
Mutton  broth  thickened  with  rice  may  be  given  to  an  older  child.  Whisky 
and  water  should  be  given  from  the  beginning.  It  is  not  too  much  to  give 
2  to  4  ounces  of  whisky  per  day.  The  physician  should  order  the  amount 
of  whisky  by  telling  the  mother  or  nurse  to  give  %  drachm  or  more  well 
diluted  with  barley  or  rice  water,  every  half -hour. 

Coffee  is  a  valuable  cardiac  stimulant.    Champagne  may  also  be  given. 

Local  Treatment. — ^The  physician  will  be  most  successful  who  places 
his  patient  in  bed,  regulates  the  diet,  cleanses  the  intestinal  tract,  and 
relieves  the  tenesmus  by  local  treatment.  The  heart  should  be  supported. 
The  strength  must  be  sustained  with  nutrition  and  the  flushing  of  the  bowel 
should  be  performed  as  soon  as  possible  after  a  stool  is  evacuated. 

Warm  chamomile  tea  should  be  used  to  cleanse  the  colon  and  rectum. 
This  should  be  injected  at  a  temperature  of  100°  to  105°  FL,  with  the  aid 
of  a  small  rubber  catheter.  This  can  be  followed  by  an  injection  of  1 
ounce  of  sterile  water  containing  2  grains  of  nitrate  of  silver.  Very  bland 
injections,  such  as 

I^  Raw  starch    1  teaspoonful 

Chamomile  tea    1  quart 

Laudanum    10  drops 

injected  at  a  temperature  of  100°  F.,  will  soothe  the  rectum  and  frequently 
relieve  tenesmus,  I  have  successfully  treated  dysentery  cases  with  the 
following : — 

IJ  Argentum  nitrate    6  grains 

Cocoa   butter    q.  s. 

M.     Form  into  twelve  suppositories. 

IJ  Oleoresin   terebinthinae    12  grains 

Extract  of  belladonna   6  grains 

Extract  of  opii  aquosa 1  grain 

Cocoa  butter    q.  s. 

M.     Form  into  twelve  suppositories. 

Sig. :     Insert  alternately  q.  3  liours.^ 

Sulpho-carbolate  of  soda,  in  doses  of  5  to  10  grains,  can  be  used 
several  times  a  day.  Bismuth  combined  with  Dovei*'s  powder  is  frequently 
valuable.  An  ice-bag  placed  on  the  abdomen  in  the  region  of  the  colon  will 
sometimes  do  good.  Very  cool  injections  of  table  salt  and  water  are  some- 
times of  value  when  hot  injections  are  not  well  borne. 

^  As  the  nitrate  of  silver  would  oxidize  the  organic  matter  contained  in  the 
second  formula,  the  suppositories  must  be  given  at  intervals  of  three  hours. 


PELLAGRA.  255 

Pellagra. 

'The  etiology  of  pcllagTa  is  still  obscure.  Jos.  Goldberger/  in  an 
extensive  study  of  this  subject  for  our  government,  found  that,  first,  this 
disease  is  essentially  rural;  second,  associated  with  poverty.  While  posi- 
tive data  are  not  available  as  to  the  real  etiological  factor,  be  it  insect 
transmission  or  diet,  the  impression  prevails  that  canned  goods,  vegetables, 
and  cereals,  especially  corn  products,  should  be  laid  aside,  and  fresh  milk, 
fresh  eggs,  and  fresh  meats  used  instead.  In  a  study  of  an  orphanage  at  Jack- 
son, Miss.,  of  211  orphans,  68,  or  32  per  cent.,  had  pellagra.  Practically 
all  of  the  cases  were  children  between  the  ages  of  6  and  12  years.  In  a 
group  of  25  children  examined,  under  6  years  of  age,  there  were  2  cases. 
In  a  group  of  66  cases  over  12  years  of  age,  there  was  1  case. 

The  exempt  group  were  found  to  subsist  on  a  better  diet  than  the 
affected  group.  In  the  diet  of  those  developing  pellagra,  a  small  amount 
of  meat  and  other  animal  protein  food  was  found.  A  large  part  of  the 
ration  consisted  of  corn,  sirup,  and  legumes.  The  inference  may  therefore 
be  safely  drawn,  that  pellagra  is  not  an  infection,  but  that  it  is  a  disease 
essentially  of  dietary  origin.  It  may  be  caused,  for  example,  by  the  ab- 
sence from  the  diet  of  essential  vitamines.  Meyer  and  Voegtlin  believe  that 
the  presence,  in  the  vegetable  food  component,  of  excessive  amounts  of  soluble 
aluminum  salts  is  the  responsible  poison  causing  this  disease. 

Symptoms. — ^The  skin  manifestations  may  either  be  a  slight  roughening 
or  thickening  of  the  affected  skin,  so  that  an  urticarial  or  erythematous 
flush  resembling  erysipelas  may  be  found.  Other  types  are  either  oedema- 
tous  or  have  an  extensive  desquamative  dermatitis.  In  fatal  cases  marked 
sloughing  of  the  skin  is  noted.  Glossitis  and  stomatitis  are  common  symp- 
toms. The  bowel  disturbance  is  usually  diarrhoeal  in  character.  Now 
and  then  a  case  will  appear  in  which  constipation  exists. 

Lorenz-  has  made  a  study  of  the  cerebrospinal  fluid  in  pellagra.  He 
finds  that: 

1.  A  lymphocytosis  of  the  cerebrospinal  fluid  does  not  occur  in  uncom- 
plicated pellagra. 

2.  Globulin  excess  of  the  spinal  fluid  is  only  occasionally  observed. 

3.  Lange's  colloidal  gold  chloride  test  is  uniformly  negative  in 
pellagra. 

4.  The  Wassermann  is  negative  with  a  few  exceptions.  In  this  in- 
vestigation the  exceptions  were  moribund  cases  which  gave  weakly  positive 
reactions  with  blood-serum. 

5.  The  spinal-fluid  findings  would  seem  inconsistent  with  a  concep- 
tion that  pellagra  is  an  infectious  disease  of  the  central  nervous  system. 

^The  Treatment  of  Pellagra.  Reprint  No.  21S  from  the  Public  Health 
Reports,  September  11,  1914. 

"Lorenz,  W.  F.,  special  expert,  United  States  Public  Health  Service,  and 
director  Wisconsin  Psychiatric  Institute. 


256  DISEASES  OF  THE  INTESTINES. 

It  is  very  evident  from  Lorenz's  examination  that  we  are  dealing  witli 
some  local  disturbing,  agent  in  which  the  gastro-intestinal  canal  is  the  part 
affected.  When  one  considers  that  the  bulk  of  cases  appear  in  those  districts 
in  which  the  food  is  largely  made  up  of  preserved,  canned,  and  desiccated 
or  packed  meats,  then  the  diet  must  be  looked  upon  as  probably  responsible 
for  the  sj^mptoms  noted. 

Treatment. — Treatment  consists  in  reducing  the  food  that  probably 
causes  the  disease,  and  adding  fresh  meat,  milk,  eggs,  vegetables,  and  legumes 
to  the  diet.  The  diet  advised  in  the  treatment  of  scurvy  is  similar  to  that 
advised  in  the  treatment  of  this  condition.  Arsenic,  atoxyl  and  salvarsan 
have  been  recommended,  but  one  and  all  found  wanting.  Small  doses  of 
quinine,  iron  and  strychnine,  codliver  oil,  olive  oil,  fresh  butter  and  fresh 
cream  will  aid  in  restoring  normal  conditions.  To  relieve  the  diarrhoea  a 
dose  of  castor  oil  followed  by  5-  to  10-  grain  doses  of  bismuth  or  tannigen 
should  be  given. 

Pood  Intoxication  (Toxicosis;  Cholera  Infantum; 
Acute  Milk  Infection)  . 

For  ma:ny  years  we  have  been  taught  that  the  ingestion  of  bacteria 
in  milk  causes  diarrhoeal  diseases.  Some  authors  have  found  one  or  more 
million  bacteria  in  1  cubic  centimeter  of  ordinary  milk;  other  specimens 
have  contained  only  50  thousand  bacteria  in  1  cubic  centimeter.  In  count- 
ing these  bacteria,  the  harmless  and  harmful  varieties  are  not  separately 
considered.  In  other  words,  bacteriologists  merely  consider  germs.  There 
are  many  forms  of  bacteria  which  normally  inhabit  the  intestine.  That 
these  innocent  bacteria  assume  a  virulent  form  under  certain  irritated  con- 
ditions has  been  suspected.  The  bacillus  of  Shiga  has  been  found  in 
many  cases  of  intestinal  catarrh  with  diarrhoea  and  symptoms  of  intoxi- 
cation. There  are  equally  as  many  cases  of  the  same  type  in  which  no 
Shiga  bacillus  can  be  found.  One  must  assume,  therefore,  that  there  are 
other  factors  equally  as  important  as  bacteria  causing  this  condition. 

It  has  been  possible  to  reduce  one  or  more  million  bacteria  in  each 
cubic  centimeter  of  raw  milk  to  50  thousand  bacteria  per  cubic  centimeter, 
by  subjecting  the  milk  to  steaming  at  a  temperature  of  140°  F.  for  ten 
minutes.  We  know  that  the  toxins  generated  by  some  bacteria  are  more 
deadly  in  their  action  than  the  bacteria  themselves.  Such  toxins  can  with- 
stand a  temperature  of  300°  F.  without  destruction. 

To  Finkelstein  belongs  the  credit  of  having  shown  that  bacteria  do  not 
enter  into  the  causation  of  this  disease,  but  that  the  faulty  assimilation 
of  fat  and  sugar  is  responsible  for  this  condition.  Finkelstein  proves  this 
by  relieving  the  symptoms  when  fat  and  sugar  are  withdrawn  from  the  food, 
and  when  the  protein  element  is  increased.  This  he  does  regardless  of  the 
presence  or  absence  of  bacteria. 


INTOXICATION.  257 

In  bottle-fed  children,  especially  among  the  poorer  classes,  acute  milk 
poisoning  is  frequently  seen  during  the  summer  months.  This  is  due 
mainly  to  the  chemical  or  toxic  product  developed  in  the  milk.  The  heat 
of  the  summer  rapidly  decomposes  milk,  and  large  quantities  of  bacteria 
multiply  and  generate  their  toxic  products.  When  such  milk  is  fed  to 
infants  they  show  the  effect  of  the  toxin  very  rapidly.  Park  found  that 
when  milk  was  first  received  from  the  farms  it  contained  from  10,000  to 
20,000  bacteria  in  each  cubic  centimeter.  On  the  second  clay  the  bacteria 
had  so  increased  that  there  were  between  10,000,000  and  30,000,000  per 
cubic  centimeter. 

Summer  diseases,  particularly  entero-colitis  and  cholera  infantum,  will 


Fig.  70. — A  Case  of  Acute  Milk  Poisoning  Having  Vomiting,  Diarrhoea, 
Mucous  and  Bloody  Stools,  General  Emaciation,  Acute  Cholera  Infantum, 
and  Dysentery.     (Original.) 

appear  just  as  readily  in  breast-fed  children  who  are  improperly  managed 
as  in  bottle-fed  children. 

Pathology. — There  is  extreme  emaciation  of  the  entire  body  affecting 
muscles  and  fat.  The  fontanel  is  depressed.  The  eyes  are  sunken.  The 
elasticity  of  the  skin  ie  gradually  lost;  the  skin  hangs  in  loose  folds.  The 
body  resembles  an  advanced  form  of  tuberculosis.  Minute  haemorrhages 
are  found  associated  with  intense  congestion  in  the  stomach  and  intestines. 
The  evidence  of  catarrh  is  everywhere  seen.  There  is  an  excessive  secretion 
of  mucus  in  the  larger  intestine ;  in  the  colon  ulcers  will  be  found. 

Ashby  and  Wright  describe  a  general  distention  of  the  net-work  of  the 
capillaries  situated  in  the  mucous  membrane  of  the  intestine.  The  same 
condition  is  found  in  the  submucosa,  in  the  villi,  and  between  the  tubules 
and  crypts  of  Lieberkiihn.  '"The  central  portions  of  the  solitary  glands 
are  softened,  or,  the  softened  portions  having  been  discharged,  the  remains 
of  the  glands  appear  as  sharply  cut  ulcers,  although  the  sinuses  of  the  brain 

17 


258  DISEASES  OF  THE  INTESTINES. 

are  found  distended  with  blood.  Occasionally  cerebral  anaemia  may  exist." 
Meningitis  is  rare. 

Bacteriology. — The  enormous  material  at  our  command  in  this  country 
gave  the  Rockefeller  Institute  an  advantage  in  studying  the  pathogenic 
bacteria  in  this  disease.  It  was  found  that  the  bacillus  dysenterise  (Flexner) 
is  present  in  very  many  cases.  Other  investigators  along  the  same  liues 
have  found  the  bacillus  pyocyaneus  (Cooper)  a  probable  causative  factor  in 
this  disease.  On  the  other  hand,  Finkelstein,  Escherich,  and  Moro  believe 
that  the  bacillus  acidophilus  is  the  causative  agent.  Other  investigators 
believe  the  bacillus  coli  communis  or  the  streptococcus  to  be  the  causative 
agent.  Finkelstein  and  Meyer  have  shown  that  milk  sugar  in  food  can  alone 
produce  intoxication.  When  a  high  fat  content  is  present,  this  naturally 
aids  in  the  intoxication  caused  by  the  sugar. 

It  is  impossible  to  believe  that  bacteria  per  se  are  not  at  the  root  of  the 
disease,  and  yet  convincing  argument  is  ofEered  by  the  German  investigators 
to  prove  their  claim:  that  the  disease  is  one  in  which  there  is  a  dietetic 
error  resulting  in,  first,  a  local ;  and  later,  a  general  systemic  disturbance. 

Causes. — The  etiological  factors  can  be  briefly  outlined  as  follows  :— 

1.  Food,  improper  quantity  and  quality  of  the  same,  be  it  breast-milk 
or  hand-feeding. 

2.  The  most  frequent  cause  is  certainly  improper  bottle-feeding, 
wherein  food  unsuited  to  the  infant's  digestive  abilities  is  continued,  in 
spite  of  Nature's  efforts  to  warn  us,  as  frequently  manifested  by  either 
vomiting  or  diarrhoea,  or  both. 

3.  Milk  from  mothers  suffering  with  tuberculosis  or  syphilis.  Preg- 
nant, menstruating,  and  all  anaemic  women  secrete  such  poor  milk  that 
gastro-enteric  derangements  are  exceedingly  common. 

4.  The  influence  of  the  weather  on  digestion,  especially  the  extreme 
heat  of  summer. 

Harry  G.,  ten  months  old,  bottle-fed,  was  brought  to  me  with  a  history  of 
vomiting,  high  fever,  and  diarrhoea.  The  temperature  was  104°  F.  The  stool  was 
green  and  contained  mucus  and  curds,  and  had  a  very  foetid  odor.  The  stools  were 
as  frequent  as  twenty  in  twenty-four  hours.  There  was  a  great  deal  of  flatulence, 
the  abdomen  was  distended,  and  there  was  constant  tenesmus.  The  mouth  was 
dry,  the  tongue  had  a  whitish  fur  coating,  and  in  the  mouth  small  patches  of 
stomatitis  could  be  seen.  Tlie  tongue  protruded  constantly  and  when  liquids  were 
given  they  were  taken  ravenously.  The  mother  stated  that  ordinary  grocer's  milk 
had  been  used,  and  that  she  believed  the  milk  had  turned  sour  "after  a  thunder 
storm."  The  diagnosis  of  acute  milk  infection  was  made.  The  stomach  was  washed 
by  the  use  of  1  quart  of  saline  solution.  Two  drachms  of  castor  oil  was  ordered, 
and  one  hour  later  the  rectum  and  colon  were  flushed  with  1  quart  of  chamomile  tea. 
All  milk  was  stopped.  No  food  was  given  for  six  hours.  A  bland  diet  of  sweetened 
rice  water  and  whey  was  then  given  in  quantities  of  4  ounces  every  two  hours.  As 
a  stimulant,  15  drops  of  whisky  was  given  with  i/ioo  grain  of  strychnine  every  three 
hours.  The  child  improved,  and  three  days  later  1  ounce  of  milk,  with  7  ounces  of 
rice  water,  was  given  every  three  hours.  The  milk  was  gradually  increased  every 
other  day,  and  the  rice  water  decreased.    The  child  recovered. 


INTOXICATION.  259 

Symptoms. — The  two  cardinal  symptoms  are  (a)  vomiting,  (b)  diar- 
rhoea. In  some  instances  the  first  evidence  of  this  infection  will  be  fever. 
The  temperature  may  be  as  high  as  103°  to  105°  F.  There  will  be  intense 
thirst.  There  is  no  appetite.  The  infant  will  refuse  its  bottle,  and  if 
forced  to  take  it  will  immediately  throw  it  off.  Bile,  mucus,  and  sour- 
smelling  curd  form  the  bulk  of  the  vomit.  The  abdomen  is  usually  dis- 
tended. There  is  a  great  deal  of  flatulence.  The  stool  is  watery  and  green- 
ish in  color,  with  a  very  foul  odor.  When  the  diarrhoea  continues  for 
several  days,  the  temperature  may  become  subnormal  and  the  infant's  fore- 
head may  be  covered  with  a  cold,  clammy  perspiration.  The  extremities 
are  usually  cold.  The  child  will  sink  very  rapidly,  owing  to  the  amount 
of  exhaustion.  The  body  is  constantly  drained  by  the  diarrhoea.  Unless 
the  clinical  picture  is  recognized  and  proper  treatment  instituted,  the 
infant  may  sink  into  a  coma  and  have  convulsions,  followed  by  death. 

The  following  case  illustrates  acute  milk  poisoning  in  an  infant  less  than  1 
year  old.  The  infant  was  bottle-fed  and  received  the  food  daily,  modified,  from  a 
milk  laboratory.  This  food  seemed  to  agree  until  the  time  of  the  present  illness. 
The  child  was  under  the  treatment  of  Dr.  John  Logan  and  Dr.  J.  Martinson,  both 
of  New  York.  The  case  was  seen  by  me  in  consultation  after  several  days'  illness. 
The  infant  was  vomiting  and  had  greenish,  mucous  stools.  There  was  severe  tenesmus. 
The  infant  showed  severe  prostration  and  was  apparently  comatose.  The  fontanel 
was  sunken.  The  pulse  was  very  feeble.  The  circulation  was  poor  and  the  extremi- 
ties cold.  As  no  food  was  retained,  in  addition  to  the  amount  of  toxin  in  the 
circulation,  the  heart's  action  became  weaker  and  weaker.  It  was  very  difficult  to 
rouse  this  child.  In  spite  of  high  saline  colon  injections,  the  child  died  of  exhaustion 
associated  with  general  toxaemia. 

Diagnosis. — The  diagnosis  of  this  condition  is  extremely  easy.  It  is 
usually  aided  by  the  clinical  history.  The  disease  usually  occurs  in  sum- 
mer, although  milk  poisoning  can  take  place  during  any  time  of  the  year. 

Differential  Diagnosis. — Sunstroke  may  sometimes  be  confounded  with 
cholera  infantum,  but  the  continued  diarrhoea  in  cholera  infantum,  and 
its  history,  should  aid  in  eliminating  this  condition  as  a  factor.  Asiatic 
cholera  shows  symptoms  similar  to  cholera  infantum.  The  presence  of  the 
comma  bacillus  in  the  stools  will  establish  the  presence  of  Asiatic  cholera. 

An  important  point  to  remember  is  that  very  many  diseases  have 
symptoms  resembling  cholera  infantum  and  must  be  carefully  differen- 
tiated; for  example,  typhoid  fever  occurring  in  midsummer  may  simulate 
this  disease  and  give  rise  to  symptoms  which  greatly  resemble  cholera  in- 
fantum. We  occasionally  see  children  having  diarrhoea,  vomiting,  and 
fever  in  whom  on  palpation  a  tenderness  in  the  ileo-csecal  region  can  be 
palpated.  Such  cases  may  have  appendicitis  and  still  show  all  the  symp- 
toms of  cholera  infantum. 

The  blood  examination  will  aid  in  establishing  the  diagnosis  of  ap- 
pendicitis. In  the  latter  condition  we  have  a  marked  leucocytosis  and  a 
high  polynuclear  percentage. 


260  DISEASES  OP  THE  INTESTINES. 

The  prognosis  depends  on  the  infant,  its  surroundings  and  the  amount 
of  infection,  and  the  length  of  illness.  An  infant  having  good  vitality  and 
being  given  a  careful  diet  and  stimulation  with  proper  hygienic  treatment 
certaialy  has  more  chance  than  one  left  in  the  city  amid  poor  surround- 
ings with  faulty  hygiene. 

Hygienic  Treatment. — Before  feeding  is  considered  we  must  put  the 
infant  into  the  best  possible  surroundings,  a  clean  room,  clean  linen,  a  clean 
bed ;  in  fact,  all  sanitary  conditions  must  be  perfect.  If  possible  the  infant 
should  be  placed  on  the  roof  of  a  house  in  the  city,  or  out-of-doors  in  the 
country,  both  day  and  night.  To  place  a  case  out-of-doors  during  the  day 
is  not  sufficient.  //  sea  air  is  obtainable,  it  is  best  to  remove  the  child  to 
the  seashore,  or  at  least  insist  on  daily  excursions.  Cold  bathing,  or  bathing 
in  cold  or  lukewarm  water,  to  which  some  sea  salt  has  been  added,  has 
proven  beneficial. 

Dietetic  Treatment. — ^After  the  hygienic  conditions  are  satisfactory,  at- 
tention should  be  directed  to  the  food.  Knowing  that  this  disease  is  caused 
by  faulty  feeding,  the  most  important  and  therapeutic  indication  is  the 
feeding.  Liberal  quantities  of  water  sweetened  with  %  grain  of  saccharine 
to  the  pint  should  be  given.  Skimmed  milk,  or  diluted  skimmed  milk,  or 
junket  made  with  skimmed  milk  is  the  best  food  for  this  condition.  Butter- 
milk made  from  the  lactic  acid  bacillus  and  skimmed  milk  should  form 
the  bulk  of  the  diet.  Rice  or  barley  water  sweetened  with  saccharine  may 
be  useful  in  controlling  the  diarrhoea.  The  intervals  of  feeding  should  be 
from  three  to  four  hours.  The  quantity  should  be  reduced.  If  the  infant 
had  been  getting  6-  or  8-  ounce  feedings,  the  quantity  should  be  reduced  to 
4  or  6  ounces  at  one  feeding.  Lime  water  may  be  given  liberally,  several 
teaspoonfuls  in  one  hour.    Weak,  cold  tea  may  be  given  ad  libitum. 

If  the  infant  is  breast-fed  discontinue  the  breast  at  least  twenty-four 
hours.  If  the  acute  symptoms  of  vomiting  and  diarrhoea  have  been  stopped 
by  appropriate  treatment,  then  the  breast  may  be  permitted  once  every  six 
or  eight  hours,  the  alternate  feeding  to  consist  of  rice  or  barley  water 
sweetened  with  saccharine.  In  other  words,  we  must  return  gradually  to 
milk  feeding.  If  acute  symptoms  return  when  the  breast-milk  is  given,  then 
it  is  a  question  as  to  whether  or  no  the  breast  should  be  entirely  withheld. 

Antipyretic  Measures. — Cold  applications  to  the  head  and  an  ice-bag 
over  the  fontanel,  cold  towels  changed  every  fifteen  or  thirty  minutes  over 
the  abdomen,  will  tone  up  the  nervous  system  in  addition  to  reducing  the 
temperature.  I  am  a  decided  opponent  to  antipyretic  drugs,  and  never  use 
antipyrin  or  phenacetine,  but  invariably  resort  to  hydropathic  measures  for 
the  reduction  of  the  temperature.  Sponging  of  the  body  with  alcohol  and 
water  is  very  grateful  and  refreshing,  besides  a  good  antipyretic  measure. 
If  cyanosis  and  cold  extremities  exist,  then  it  is  wise  to  resort  to  hot 
mustard  baths  to  stimulate  the  circulation. 


INTOXICATION.  261 

Drug  Treatment. — The  tendency  to  constipation  following  a  dose  of 
castor-oil  makes  it  a  valuable  remedy  in  all  forms  of  diarrhoea.  Bismuth  is 
the  sovereign  remedy;  I  have  used  the  subcarbonate,  subnitrate,  salicylate, 
and  betanaphthol  bismuth,  and  find  the  latter  an  extremely  valuable  prepara- 
tion. In  doses  of  2  to  5  grains  every  few  hours,  mixed  with  a  little  boiled 
water,  it  not  only  agrees  very  well  with  children,  but  seems  to  exert  a  heal- 
ing effect  in  that  form  of  bacillary  diarrhoea  which  is  met  with  in  the  acute 
catarrhal  gastro-enteritis. 

Salol  in  doses  of  1,  2,  and  3  grains,  for  each  year  respectively,  is  an- 
other valuable  remedy;  so  also  is  resorcin,  in  doses  of  1/4  to  1  grain  for 
a  child  1  year  old,  three  or  four  times  a  day.  It  is  advisable  not  to  add 
sugar  for  sweetening,  but  only  glycerine,  the  latter,  however,  in  very  small 
quantities,  as  it  has  a  tendency  to  loosen  the  bowels. 

Tannalbin  and  tannigen  in  doses  of  from  1  to  10  grains  seem  to  act 
well  in  some  cases,  poorly  in  others,  but  are  well  worth  trying  in  those 
desperate  cases  in  which  we  change  the  drugs,  if  they  are  ineffectual. 

Hypodermic  Medication. — In  forms  of  collapse,  where  constant  diar- 
rhoea has  drained  the  system,  it  is  a  good  plan  when  the  extremities  are  cold 
to  give  hypodermic  injections  of  10  to  20  drops  of  whisky.  Sulphuric  ether 
can  also  be  administered  hypodermically  in  the  same  dose  as  whisky.  An 
intravenous  injection  of  1  pint  of  normal  saline  solution  containing  a 
drachm  of  adrenaline  solution  1 :  2000  may  be  given.  Another  valuable 
stimulant  is  musk;  2  to  3  drops  of  tincture  of  musk  administered  hypo- 
dermically every  hour  will  frequently  rouse  the  circulation. 

When  this  form  of  treatment  proves  unsuccessful,  and  the  condition  of 
collapse  continues,  then  a  good  plan  is  to  resort  to  hypodernioclysis.  This 
consists  of  introducing  a  long  aspirating  needle  (previously  sterilized  by 
boiling)  into  the  loose  connective  tissue  of  the  abdomen,  and  allowing  sev- 
eral ounces  of  the  normal  saline  solution,  containing  about  7^/2  grains  of 
table  salt  to  a  pint  of  water,  temperature  100°  F.,  to  flow  in  subcuta- 
neously.  It  is  remarkable  to  note  how  much  liquid  can  be  introduced  in 
this  manner,  and  some  of  the  most  desperate  cases  of  collapse  will  respond 
very  rapidly.  I  have  seen  children  who  previous  to  this  injection  were 
pulseless  suddenly  brighten  up,  and  within  a  few  minutes  show  a  distinct 
radial  pulse.  Too  much  care  cannot  be  bestowed  on  the  sterilization  of 
every  part  of  the  apparatus,  and  the  absolute  cleanliness  of  the  water  to  be 
used  for  this  purpose. 

Rectal  and  Colon  Flusliing. — It  is  advisable  to  irrigate  the  colon  and 
rectum  by  placing  the  child  on  its  left  side,  introducing  a  flexible  rubber 
tube  anointed  with  carbolized  vaseline.  Having  passed  the  external  sphinc- 
ter, I  invariably  allow  the  water  to  flow  into  the  rectum  in  order  to  balloon 
the  same,  and  then  continue  to  push  the  tube  beyond  the  rectum  into  the 
colon.     A  little  difficulty  is  sometimes  encountered,  owing  to  the  spas- 


263  DISEASES  OF  THE  INTESTINES. 

modic  contraction  of  the  muscles,  but  if  we  wait  a  short  time,  using  a  little 
patience,  the  tube  can  easily  be  pushed  into  the  colon.  The  method  pur- 
sued is  the  same  as  described  previously  in  irrigating  the  stomach,  excepting 
that  we  do  not  seek  to  syphon  ofE  the  contents  of  the  bowels,  but  rather  allow 
a  pint  or  a  quart  of  the. warm  saline  solution  to  flush  the  bowels,  and  in 
this  manner  wash. away  as  much  of  the  offending  debris  as  exists  within  the 
bowels.  I  have  frequently  used  cold  water,  but  I  find  much  greater  benefit 
from  the  use  of  a  warm  solution  of  the  temperature  of  105°  F. 

Some  of  our  cases  require  irrigation  once  in  twenty-four  hours  for  one 
week,  and  others  again  are  so  greatly  improved  after  one  rectal  washing  that 
it  is  not  necessary  to  resort  to  it  again. 


Fig.  71. — Exact  Size  of  Catheter  Used  for  Irrigating  a  Very  Young  Infant. 

Starch  injections,  made  by  adding  2  tablespoonfuls  of  the  ordinary 
starch  to  a  quart  of  warm  water  of  a  temperature  of  105°  F.,  may  be  gi^en. 
They  are  very  advantageous,  as  the  colon  changes  starch  into  dextrin, 
which  is  easily  absorbed.  Thus  not  only  does  the  latter  cleanse,  but  it  is 
also  nutritious.  Large  quantities  of  saline  solution  can  be  introduced 
into  the  circulation  by  means  of  colon  washing,  thus  adding  to  the  volume 
of  the  blood,  I  tlierefore  lay  great  stress  on  this  form  of  treatment,  as 
one  of  the  most  valuable  for  this  depleting  condition.  Thromboses  can 
frequently  be  avoided  by  these  injections. 

When  severe  tenesmus  exists,  painting  of  the  lower  end  of  the  rectum 
with  a  2  per  cent,  solution  of  cocaine  is  frequently  very  advantageous.  Pro- 
lapse of  the  rectum  and  anus  can  frequently  be  prevented  by  applying  a 
strip  of  zinc  oxide  plaster  from  one  buttock  tightly  to  the  other,  so  that  the 
buttocks  will  support  the  bowel  and  mechanically  prevent  its  protrusion. 

SUMMEE  DlAEKHffiA, 

In  this  condition  we  have  a  gastro-intestinal  disorder  due  to  the  toxins 
generated  from  the  bacteria  in  milk.  This  usually  occurs  during  the  sum- 
mer months,  when  there  is  great  humidity  in  the  air.  The  symptoms  are 
not  so  severe  as  those  seen  in  the  acute  form  of  milk  infection.  It  is  usually 
met  with  among  the  poorer  classes,  who  buy  a  cheap  milk  which  usually 
contains  millions  of  bacteria.  Victor  Vaughn,  of  Ann  Arbor,  Mich.,  in.  a 
letter  to  me,  stated  that  although  it  is  possible  to  destroy  all  bacteria  by 
repeated  and  continued  sterilization,  he  found  it  impossible  to  destroy  the 
toxins  generated  in  milk  even  though  the  temperature  was  raised  to  300°  F. 

Cause  of  Infant  Mortality. — The  weeds  eaten  by  cows  in  their  summer 
pastures  are  responsible  for  many  cases  of  gastro-intestinal  disease.     Many 


bUMMEil  DixViliUiCLlA.  i>G3 

of  these  weeds  are  poisonous  and  their  juices  pass  into  the  milk.  In 
support  of  this  theory  Hauser  gives  the  statistics  of  mortality  in  a  number 
of  districts  in  his  experience,  classifying  them  by  the  soil  and  the  weeds 
that  grow  by  preference  on  certain  soils. 

Bacteriology. — BacteriologicaP  investigation  of  summer  diarrhoea  com- 
menced when  Escherich,  in  1886,  published  his  work  on  the  intestinal 
bacteria  of  infants  and  their  relation  to  the  physiology  of  digestion. 
Lesage,  Hayem,  and  Baginsky  contributed  further  researches,  but  the  most 
important  and  exhaustive  researches  were  made  by  Booker  from  1886  to 
1897.  As  the  result  of  these  he  called  attention  to  three  principal  forms 
of  summer  diarrhoea,  based  on  a  correspondence  of  their  clinfcal,  anatom- 
ical, and  bacteriological  features:  (1)  dyspeptic  or  non-inflammatory  diar- 
rhoea, in  which  the  obligatory  milk-faeces  bacteria  are  found,  chiefly  the 
bacillus  coli  communis,  the  bacillus  lactis  aerogenes  appearing  in  smaller 
numbers;  (2)  streptococcus  gastro-enteritis,  in  which  there  is  a  general 
infection  and  ulceration  of  the  intestine,  with  streptococci  as  the  pre- 
dominating forms,  some  bacilli  being  present  as  well;  (3)  bacillary  gastro- 
enteritis characterized  by  a  general  toxic  condition  with  less  intestinal 
inflammation,  and  the  presence  in  the  stool  of  several  varieties  of  bacilli, 
the  proteus  vulgaris  being  the  most  common. 

Escherich  studied  the  streptococcus  cases  more  closely  (1897-1899) 
and  found  the  cocci  numerous  and  in  almost  pure  culture  in  the  stools  in 
acute,  severe  cases,  while  it  was  possible  to  isolate  them  from  the  urine 
and  the  blood  during  life  and  from  the  viscera  after  death.  Clinically,  the 
symptoms  vary  much  in  the  mild  and  the  severe  cases;  the  stools  may  be 
watery  and  contain  much  pus  and  blood.  Staphylococci  have  also  been 
found  in  diarrhoeal  stools,  but  much  less  frequently  than  streptococci.  Later 
Escherich  described  cases  of  dysentery  due  to  a  virulent  colon  bacillus. 
Valagussa  found  a  bacillus  belonging  to  the  colon  group  and  identical  with 
that  isolated  by  Colli  and  Fiocca  from  cases  in  Italy  and  Egypt.  In  1898 
Shiga,  in  Japan,  described  the  bacillus  dysenteriae,  an  organism  more  nearly 
related  to  the  typhoid  than  to  the  colon  group,  and  Flexner  found  the  same 
bacillus  in  one  form  of  acute  dysentery  studied  in  Manila.  Both  Celli  and 
Escherich  tried  to  identify  the  bacillus  they  described  with  that  of  Shiga. 
The  bacillus  pyocyaneus  has  also  been  found  in  the  stools  of  cases  of 
epidemic  infantile  dysentery.  It  is  evident,  then,  that  no  specific  bac- 
terium of  gastro-enteritis  has  been  found;  there  is  one  form  in  which  the 
streptococcus  is  the  predominating  organism,  and  the  bacillus  dysenteriae 
may  possibly  be  proved  to  be  the  cause  of  epidemic  dysentery  both  in  chil- 
dren and  in  adults. 

Pathology. — Inflammatory  lesions  and  ulcerations  can  be  seen  in  the 
colon.    It  is  rare  to  find  the  duodenum  and  jejunum  involved.    The  micro- 

"^An  editorial  in  Archives  of  Pediatrics,  August,  1901. 


264  DISEASES  OF  THE  INTESTINES. 

scopical  findings  of  the  stool  sliow  numerous  bacteria,  epithelial  cells,  de- 
tritus, and  occasionally  blood.    Sometimes  particles  of  food  are  also  seen. 

Symptoms. — Vomiting  and  diarrhoea  as  in  the  acute  form  are  the  main 
sjmiptoms.  If  an  infant  has  just  recovered  from  an  acute  milk  infection 
and  is  placed  on  milk  feeding  too  soon,  a  relapse  frequently  occurs,  which 
is  a  subacute  infection.  The  stools  are  gTeenish  and  resemble  those  de- 
scribed in  the  acute  form.  There  is  a  loss  of  appetite,  a  coated  tongue,  and 
the  temperature  ranges  between  101°  and  105°  F. ;  at  times  the  tempera- 
ture may  be  normal  or  subnormal.  The  infant  does  not  want  to  be  dis- 
turbed, and  is  very  irritable.  The  irritation  and  tenesmus  accompanying 
this  diarrhoea  usually  cause  the  rectum  to  prolapse,  and  from  the  constant 
discharges  of  the  bowel  the  anus  and  buttocks  are  excoriated.  An  eczem- 
atous  eruption  frequently  is  seen  between  the  thighs.  Local  infection  of 
the  skin  and  lymphatics,  by  the  presence  of  the  pyogenic  bacteria,  some- 
times causes  furuncles. 

Biag^nosis. — This  is  usually  made  when  the  history  and  symptoms  are 
carefully  noted.  It  is  much  milder  than  cholera  infantum.  The  tempera- 
ture is  lower,  the  vomiting  less,  and  the  prostration  not  so  marked. 

Jonah  W.,  seven  months  old,  twin  baby,  bottle-fed,  had  been  constipated  since 
birth.  There  was  a  slight  cough.  The  child  had  beaded  ribs,  craniotabes,  and  bald- 
ness of  the  occiput.  Since  one  month  he  had  vomiting  and  diarrhoea.  This  had 
improved  and  disappeared  entirely.  The  child  was  given  milk,  and  ten  days  after 
the  milk  diet  was  commenced  the  symptoms  of  vomiting  and  diarrhoea  again  appeared, 
but  in  a  milder  form.  Several  furuncles  were  found  on  his  scalp.  Owing  to  the 
intolerance  of  milk,  whey  was  given  in  the  same  quantity  and  frequency  as  the  milk 
was  formerly  given.  Rice  water,  barley  Avater,  and  thickened  pea  soup  wei'e  allowed. 
Toast  Avater  was  given  for  thirst.  Cocoa  was  also  given  without  milk.  The  cocoa 
was  made  with  rice  water,  in  the  following  proportions: — 

IJ   Cocoa 1  drachm 

Rice  water    8  ounces 

Saccharine %  grain 

Scald  about  five  minutes. 

A  large  dose  of  castor  oil  followed  by  a  2-grain  dose  of  tannopine  every  two 
hours  was  given.  A  high  saline  injection,  1  quart,  temperature  115°  F.,  was  ordered 
to  cleanse  the  rectum  and  colon ;  also  for  its  stimulating  effect. 

The  diagnosis  of  subacute  milk  infection,  congenital  syphilis,  and  furunculosis 
was  made.    The  case  recovered. 

Prognosis  and  Complications. — This  depends  on  the  condition  of  the 
child.  If  there  is  a  complication  such  as  nephritis  present,  then  the  prog- 
nosis is  worse  than  if  uncomplicated.  If  an  infant  can  be  removed  to  the 
seashore  from  unsanitary  surroundings  and  proper  food  given,  the  prog- 
nosis is  good. 

Treatment. — ^Two  points  to  be  considered  in  this  condition  are :  First, 
stop  all  milk  for  at  least  one  week  and  give  the  stomach  and  bowels  absolute 


SmiMER  DIARRHCEA.  265 

rest.  Second,  cleame  the  stomach  and  howels  of  all  offending  debris  which 
may  have  caused  this  trouble.  Such  cases  sliould  be  put  on  a  light,  nutri- 
tious diet. 

The  golden  rule  is  to  give  the  stomach  and  bowels  absolute  rest  in  both 
quality  and  quantity  of  food.  The  feeding  interval  should  be  longer  and 
the  amount  of  food  reduced. 

In  substituting  other  forms  of  feeding,  pro  tempore,  we  invariably  do 
so  at  the  expense  of  body  weight.  It  will  always  be  noted  that  children 
deprived  of  milk  will  lose  weight  unless  care  is  taken  to  substitute  a  proper 
nutritious  food.  The  body  will  lose  to  such  an  extent  that  atrophy  may 
frequently  follow. 

Formula  for  Weak  Infants  in  Substitute  Feeding. — When  vomiting  and  diar- 
rhoea persist  give  either:  — 

Barley  water    4  ounces 

Rice  water    4  ounces 

Oatmeal  water  4  ounces 

Or:  — 

Whey   4  ounces 

Feed  every  two  or  three  hours.    Add  %  of  yolk  of  egg  to  each  feeding. 

If  fermentation  exists — colic,  greenish  stools,  and  eructations — use 
saccharine,  %  grain,  instead  of  sugar  for  sweetening. 

The  liquid  culture  of  the  Bulgarian  bacillus  generates  lactic  acid.  This 
liquid  culture  has  sensed  me  very  well  in  acute  enterocolitis,  and  especially 
to  control  fermentation  and  colic  caused  by  intestinal  toxic  bacteria.  The 
liquid  culture  in  drachm  doses,  repeated  every  three  or  four  hours,  is  non- 
toxic. Older  children  may  also  have  junket,  cream  cheese,  albumin-water 
and  expressed  beef-juice. 

Medicinal  Treatment. — A  dose  of  castor-oil  should  be  given  at  the 
beginning  of  the  treatment,  first  to  cleanse  the  gastro-intestinal  tract,  and 
secondly,  for  its  constipating  after-effect.  Rhubarb  and  soda  mixture  in 
doses  of  one-half  teaspoonful  is  valuable  after  the  castor-oil  has  been  given. 
The  treatment  described  in  the  article  on  "Intoxication"  should  be 
carried  out  as  well  in  this  condition.  The  successful  outcome  of  the 
case  depends  on  proper  rest,  careful  stimulation,  and  a  thorough  cleansing, 
aided  by  a  decided  change  of  air,  to  the  seashore  or  to  the  mountains.  Milk 
should  not  be  given  until  all  conditions  appear  normal.  Essence  of  caroid 
in  teaspoonful  doses,  every  three  hours,  is  serviceable.  Powdered  caroid 
combined  with  charcoal,  in  doses  of  3  grains  each,  repeated  several  times  a 
day,  is  very  valuable. 

Carbolic  acid  is  extolled  by  some  physicians  with  large  experience  in 
infantile  diseases.  S.  Henry  Dessau  strongly  advises  a  1  per  cent,  solution 
of  carbolic  acid  as  an  intestinal  corrective  when  fermentation  exists.  He 
has  not  seen  any  toxic  symptoms  from  its  use.     I  can  fully  indorse  his 


3(36  DISEASES  OF  THE  INTESTINES. 

statement  and  nsually  advise  watching  the  urine  during  the  administration 
of  carbolized  water.  A  teaspoonful  of  a  1  per  cent,  solution,  sweetened 
with  saccharine,  can  be  given  three  or  more  times  a  day.  If  no  effect  is 
noticed  in  twentj^-four  hours,  then  1%  or  2  teaspoonfuls  can  be  given  at 
each  dose.  I  have  also  used  creosote  water,  1  per  cent,  solution,  in  the  same 
doses  as  carbolized  water  with  excellent  results.^ 

CoiSrSTIPATION  AND   ChRONIC    CONSTIPATION. 

The  bowels  of  an  infant  during  the  nursing  period  should  have  one 
or  two  evacuations  daily.  Some  children  will  be  quite  normal  with 
one  evacuation  daily.  Older  children  who  partake  of  solid  food  suffer 
more  frequently  with  constipation.  There  are  decided  peculiarities  noted 
in  children  with  reference  to  the  movements  of  the  bowels.  One  child 
will  enjoy  good  health,  have  a  good  appetite,  and  will  gain  in  weight  with 
three  or  four  movements  of  the  bowels  daily.  Another  child  in  equally 
good  health  will  have  but  one  movement  daily.  These  differences  or 
peculiarities  must  be  taken 'into  consideration  before  definitely  maintain- 
ing that  our  patient  is  really  constipated. 

The  colon  ascendens  being  very  short,  the  surplus  of  length,  partic- 
ularly as  the  transverse  colon  also  is  not  long,  belongs  to  the  descending 
colon,  and  especially  to  the  sigmoid  flexure.  Drandt  found  it  between  8 
and  24  centimeters  in  length,  avera,ging  from  14  to  20  centimeters.  Jacobi 
saw  a  case  in  which  it  was  30  centimeters  long. 

As  the  pelvis  is  very  narrow,  the  great  length  of  the  lower  part  of  the 
large  intestine  is  the  cause  of  multiple  flexures,  instead  of  the  single  sig- 
moid flexure  of  the  iadult.  Thus  it  is  that,  now  and  then,  two  or  even 
three  flexures  are  found,  and  to  such  an  extent  that  one  of  them  may  be 
found  to  extend  as  far  as  the  right  side  of  the  pelvis.  Cruveilhier  and 
Sappey  speak  of  this  position  of  the  loAver  part  of  the  intestine  in  the 
right  side  of  the  pelvis  as  an  anomaly.  Huguier  finds  it  on  the  right  side 
of  the  body  in  the  majority  of  cases.  Others  only  occasionally,  although 
they  admit  the  great  length  of  the  sigmoid  flexure.  In  common  with 
Huguier,  who  even  proposes  to  operate  for  artificial  anus  in  the  right  side, 
Jacobi  found  one  of  the  flexures  on  the  right  side  many  times. 

The  great  length  of  the  large  intestine  and  the  multiplicity  of  its 
flexures  are  of  great  functional  importance.  At  all  events,  they  retard  the 
movement  of  the  intestinal  content,  facilitate  the  absorption  of  fluids,  and 
thus  the  fseces  are  rendered  solid.  When  this  length  is  developed  to  an 
unusual  extent,  constipation  is  the  natural  result. 

Records  of  post-mortem  observations  made  by  Dr.  T.  C.  Martin^  prove 

^  See  chapter  on  "Decomposition"  for  general  treatment  of  Summer  Diarrhoea. 

^  "A  Study  of  the  Dilficulties  of  Defecation  in  Infants,"  by  Dr.  T.  C.  Martin, 
read  at  the  forty-eighth  annual  meeting  of  the  American  Medical  Association,  June 
4,  1897. 


CONSTIPATION. 


267 


¥i".  72. — Ascending  Position. 


Fig.  73. — Ascending  Position. 


Fig.  74. — Transverse  Position. 


Fig.  75. — Transverse  Position. 


/ 


Fig.  70. — Descending  Position. 


Fig.   77. — Descending  Position. 


Il>ustrations  of  tlie  various  types  of  abnormality  of  the  sigmoid 
flexure,  whicli  are  the  source  of  habitual  constipation  in  infants.  (After 
Marfan  and  Neter.) 


268  DISEASES  OF  THE  INTESTINES. 

that  the  muscular  development  of  the  adult  rectum  and  lower  sigmoid  is 
plainly  apparent,  and  that  a  deficient  muscularity  is  observable  in  the  in- 
fant specimens.  In  the  infant  gut  the  intrinsic  power  of  peristalsis  is  not 
present  in  that  degree  necessary  to  it  as  a  competent  expulsory  factor. 

The  nieso-peritoneum  of  these  parts  in  the  adult  is,  relatively,  very 
considerably  shorter  than  that  in  the  infant.  The  adult  gut  is  slightly 
tortuous;  that  of  the  infant  is  much  angulated.  Mobility  and  angulation 
of  the  infant  gut  conspire  to  obstruct  the  passage  of  formed  faeces. 

The  rectal  valve  appears  to  bear  the  same  proportion  to  the  gut  in  both 
adult  and  infant,  but  when  the  difference  in  muscular  development  in  the 
two  is  noticed  the  disproportionate  great  resistance  of  the  valve  in  the 
infant  rectum  becomes  an  obvious  fact. 

Causes. — This  condition  is  most  frequently  met  with  in  bottle-fed 
infants.  It  is  sometimes  caused  by  a  deficiency  in  the  amount  of  sugar,  or  a 
deficiency  in  the  amount  of  fat  in  the  infant's  food.  An  insufficient  quan- 
tity of  water  in  the  diet  is  sometimes  responsible. 

In  dyspeptic  or  rachitic  infants  the  peptic  and  intestinal  glands  do  not 
perform  their  normal  functions;  this  absence  of  intestinal  glandular  secre- 
tions is  one  of  the  main  factors  in  the  causation  of  this  condition.  In- 
complete peristalsis,  such  as  exists  in  the  rachitic  debility  of  the  muscular 
layer,  in  the  muscular  debility  dependent  upon  sedentary  habits  and  peri- 
tonitis, intestinal  atrophy,  and  hydrocephalus,  results  in  constipation.  Boil- 
ing or  sterilizing  the  milk  fed  to  infants  renders  it  constipating. 

Symptoms.— Some  children  are  in  apparent  health;  others  show  con- 
stant crying,  with  the  legs  draAvn  up;  flatulence  and  a  distended  abdomen 
are  the  symptoms  most  frequently  noted.  A  temperature  of  102°  to  104° 
may  sometimes  be  caused  by  the  stagnation  of  f^cal  matter  in  the  intestinal 
tract.  Loss  of  appetite,  restlessness  at  night,  may  frequently  be  noted  in 
such  infants.  In  older  children  anorexia,  headache,  and  stomachache  will  be 
described.    Eructations  and  flatulence  usually  accompany  constipation. 

Diagnosis. — Before  the  diagnosis  of  constipation  is  made,  we  must  be 
sure  to  exclude  pyloric  stenosis,  intestinal  obstruction,  or  incarcerated  her- 
nia as  a  possible  cause  of  this  condition.  In  like  manner  cystic  tumors  in 
the  intestine  may  give  rise  to  sj^mptoms  of  constipation.  We  must  also 
exclude  the  possibility  of  our  dealing  with  a  case  of  Hirschsprung's  disease. 

The  diagnosis  should  not  be  made  without  bimanual  examination.  In 
most  of  the  cases  the  abdomen  is  inflated,  though  it  be  painless.  The 
faeces  come  away  in  small,  hard  lumps  or  in  large  masses.  The  liver  and 
spleen  are  displaced.  The  liver  may  be  so  turned  that  a  part  of  its  posterior 
surface  comes  forward.  The  abdominal  veins  are  enlarged  to  such  an 
extent  that  they  form  circles  around  the  umbilicus,  similar  to  what  is  seen 
in  hepatic  cirrhosis.  These  children  lose  their  appetite,  sometimes  vomit, 
and  the  irritation  produced  by  the  hardened  masses  in  the  intestinal  canal 


CONSTIPATION.  269 

may  be  such  as  to  finally  result  in  diarrhoea,  which,  however,  is  not  always 
sufficient  to  empty  the  tract. 

There  is,  besides,  an  apparent  constipation,  which  should  not  be  mis- 
taken for  any  of  the  above  varieties.  Now  and  then  a  ehil'd  will  appear  to 
be  constipated,  have  a  movement  every  two  or  three  days,  and  at  the  same 
time  the  amount  of  faeces  discharged  is  very  small.  This  apparent  con- 
stipation is  seen  in  very  young  infants  rather  than  in  those  of  more  ad- 
vanced age.  Such  children  are  emaciated,  sometimes  atrophic.  They  ap- 
pear to  be  constipated  because  of  lack  of  food,  and  not  infrequently  this 
apparent  constipation  is  relieved  by  a  sufficient  amount  of  nourishment. 

Treatment.- — Our  aim  should  be  to  modify  the  food,  if  the  same  is  at 
fault.  It  must  be  remembered,  however,  that  many  factors  may  induce 
coprostasis ;  for  example,  deficiency  in  the  tone  of  the  intestinal  muscles  and 
insufficient  peristaltic  waves  result  in  the  stagnation  of  the  intestinal  con- 


Fig.  78. — Rubber  Bulb  Syringe. 

tents.  Deficient  secretions  of  the  intestinal  glands  favor  constipation,  so 
also  a  deficient  secretion  of  bile. 

The  indications  for  the  treatment  of  a  given  case  of  constipation  de- 
pend upon  the  cause  which  leads  thereto.  If  an  atony  of  the  gastro-intes- 
tinal  tract  with  deficient  peristalsis  exists,  then  stimulation  by  means  of 
massage  should  be  carried  out.  In  addition  thereto  nux  vomica  in  the 
form  of  tincture  should  be  given  in  1-  or  2-  drop  doses  three  times  a 
day. 

For  the  immediate  relief  of  constipation  in  an  infant  a  glycerine  or 
gluten  suppository  should  be  used.  If  this  is  not  effectual,  an  injection  of 
%  pint  castile-soap  water  should  be  given.  When  constipation  per- 
sists, it  may  be  necessary  to  give  a  soap-water  injection  every  evening  for 
many  weeks.  There  is  no  danger  in  this  procedure  even  though  it  be  con- 
tinued for  several  months. 

When  hard,  dry,  scybalous  masses  are  passed  and  the  infant  strains 
considerably,  it  is  advisable  to  inject  2  ounces  of  lukewarm  sweet  oil.  with 
a  small  syringe,  before  the  infant  retires.  If  the  buttocks  are  supported 
for  several  minutes  after  such  injection,  we  favor  the  retention  of  the  oil. 
Such  oil  injections  will  soften  the  hardened  masses  and  favor  their  expul- 
sion the  following  morning. 

If  constipation  cannot  be  relieved  by  the  simple  methods  above  pro- 


270  DISEASES  OF  THE  INTESTINES. 

posed,  it  may  be  necessary  to  use  a  catheter  inserted  between  six  and 
eight  inches  into  the  colon.  If  we  inject  .  about  8  ounces  of  warm 
water  and  %  teaspoonful  of  the  inspissated  ox-gall  into  the  colon,  we 
will  have  excellfent  results.  Owing- to  the  irritating  nature  of  the  ox-gall,  its 
use  should  be  restricted  to  fever,  or  when  the  child  is  very  ill,  and  we  aim 
at  a  rapid  evacuation  of  the  colon  and  rectum. 

Drug  Treatment. — No  one  should  expect  to  cure  a  constipation  by  the 
use  of  drugs  alone.  There  are  so  many  factors  which  must  be  considered 
that  drugs  form  but  one  part  of  the  treatment. 


^^sH^ 


Fig.  79. — Irrigator,  with  Tube  Attached  and  Hard-rubber  Points. 


For  older  children,  a  teaspoonful  of  maltine  with  cascara  sagrada  taken 
in  the  morning,  once  only,  is  an  excellent  laxative.  When  a  large  quantity 
of  starchy  food  is  fed,  resulting  in  an  excess  of  acid,  calcined  magnesia 
should  be  given.  In  rachitic  and  general  atonic  conditions  %  to  1  tea- 
spoonful of  olive-oil  or  codliver-oil  may  be  ordered  three  times  a  day, 
or  aromatic  albolene,  1  teaspoonful  in  the  morning  as  a  laxative. 

Dietetic  Treatment. — For  a  very  young  infant,  %  teaspoonful  of 
malt  extract,  or  1  teaspoonful  of  Loefflund's  malt  soup,  may  be  added 
to  each  feeding.  In  estimating  the  required  dose  of  malt  soup  it  is  impor- 
tant to  supervise  daily  the  frequency  and  character  of  the  movements. 
Individual  peculiarities  must  be  considered.  One  infant  will  have  an  ex- 
cellent result  from  1  teaspoonful  added  to  the  morning  feeding,  whereas 
other  infants  will  require  the  same  dose  added  to  every  feeding.     Milk  of 


CONSTIPATION. 


271 


magnesia,  1  teaspoonful  given  in  the  morning,  to  bottle-fed  infants,  dur- 
ing the  first  half-year,  is  an  excellent  corrective.  The  method  of  heating 
the  food,  the  source  of  the  milk  supply,  and  the  quantity  of  water  given 
the  infant  are  all  factors  to  be  considered  when  dealing  with  an  infant  suf- 
fering from  constipation.  Instead  of  using  plain  water  as  a  diluent  of  the 
food,  use  oatmeal  water,  if  constipation  persists.  Sometimes  diluting  the 
milk  with  a  5  per  cent,  solution  of  sugar  of  milk  will  relieve  this  condition. 

For  infants  over  1  year  a  small  saucer  of  oatmeal  porridge  containing 
a  drachm  of  butter  may  be  tried.  A  teaspoonful  of  sugar  of  milk  may  be 
added  to  one  feeding. 

It  must  be  remembered  that  bread,  potato,  macaroni,  and  most  of  the 
carbohydrate  foods  have  a  tendency  to  constipate.  Prunes  and  senna  leaves 
stewed  to  a  jelly  in  sugar  and  water,  apple  sauce,  oranges,  grapes,  and  grape 
jelly  all  have  a  laxative  tendency.  When  the  casein  of  milk  is  altered  by  the 
Bulgarian  bacillus  into  a  casein  lactate  it  has  a  laxative  tendency.     All 


Fig.  so. — Soft-rubber  Rectal  Tube  for  Irrigating  the  Colon. 


fermented  milks  and  buttermilks  loosen  the  bowels.  One  or  2  oimces 
of  fermented  milks  may  be  given ;  large  quantities  produce  colic. 

Exercise. — What  massage  is  for  a  young  infant,  exercise  is  for  an  older 
child.  Thus,  it  is  apparent  that  atonic  conditions  can  best  be  relieved  by 
combating  the  dietetic  and  medicinal  treatment  with  out-of-door  exercise. 
Children  should  be  permitted  to  romp  about  and  walk  and  play  out  of  doors, 
but  not  to  a  point  approaching  fatigue.  Older  children  will  find  bicycle 
exercise  or  horseback  riding  decidedly  beneficial.  It  is  important,  however, 
to  regulate  the  amount  of  such  exercise,  and  thus  it  is  the  physician's  duty 
to  tell  the  mother  or  nurse  just  how  long  a  child  should  be  permitted  to 
exercise.  It  would  seem  that  one-half  hour  twice  a  day  is  ample  to  arrive 
at  beneficial  results.  Overindulgence  in  such  sports  will  frequently  result  in 
rupture  and  produce  heart  strain.  In  cardiac  lesions,  in  asthmatic  condi- 
tions, if  children  suffer  with  whooping-cougii,  and  in  tuberculous  conditions, 
such  exercises  must  not  be  allowed. 

Massage. — Continued  kneading  of  the  abdomen  with  the  aid  of  vase- 
line or  oil  will  be  found  serviceable,  and,  if  properly  done,  will  provoke  an 
action  of  the  bowel.  Thus  it  is  that  rubbing  the  abdomen  with  castor-oil 
has  frequently  been  recommended  in  the  treatment  of  constipation;  the 


372  DISEASES  OF  THE  INTESTINES. 

effect  supposed  to  be  due  to  the  castor-oil  is,  in  reality,  due  to  the  massage, 
and  to  nothing  else.  When  vibratory  massage  is  used,  it  should  be  con- 
tinued from  five  to  ten  minutes  every  day  for .  one  month.  This  will  cer- 
tainly aid  and  stimulate  peristalsis,  and  ultimately  tone  the  muscles  and 
cure  the  constipation. 

The  hands  are  gently  placed  on  the  right  side  of  the  abdomen  at  .about 
the  ileo-csecal  region.  Gentle  pressure  should  be  made;  otherwise,  the 
abdominal  muscles  will  be  tense.  Commence  each  stroke  of  the  massage 
with  gentle  pressure  and  utilize  each  inspiration  for  firmer  and  firmer 
pressure.  The  same  method  of  palpation  which  is  employed  for  the 
diagnosis  of  a  tumor  in  the  deep  tissues  should  be  employed.  After  firm 
pressure  has  been  made,  we  can  then  gradually  massage  by  a  rotary  move- 
ment, first,  the  ascending  colon,  continue  over  the  transverse  colon,  and 
finally  over  the  descending  colon  and  rectum.  Hardened  scybala  can  fre- 
quently be  felt  in  the  region  of  the  caecum  and  can  be  propelled  by  this 
mechanical  treatment  through  the  various  portions  of  the  colon  to  the 
rectum. 

Massage  from  five  to  ten  minutes  morning  and  evening  may  be  con- 
tinued several  weeks.  If  improvement  is  noted,  then  less  frequent  treatment 
is  required.  To  be  successful,  several  months  of  treatment  may  be  neces- 
sary in  obstinate  cases.  We  must  persist  in  stimulating  the  peristaltic 
waves  regularly  and  not  be  disappointed  if  immediate  results  are  not 
secured.  My  plan  has  always  been  to  inform  the  parents  that  I  do  not 
expect  any  success  in  a  chronic  constipation  which  has  persisted  for  months 
or  years,  until  six  months  or  more  have  passed. 

Electricity. — This  is  very  valuable  to  stimulate  peristalsis.  The 
faradic,  galvanic,  or  static  current  can  be  used.  For  the  general  practi- 
tioner the  use  of  the  galvanic  current,  five  to  ten  cells,  is  sufficient.  The 
negative  pole  (cathode)  should  be  applied  in  the  rectum,  and  the  positive 
pole,  which  produces  peristaltic  waves,  should  be  applied  over  the  ascend- 
ing, descending,  and  transverse  colon.  Local  contractions  result  from  the 
negative  pole.  A  gentle  faradic  current  applied  over  the  spine  and  the 
abdomen  will  answer  if  used  for  several  minutes  in  the  absence  of  "the 
galvanic  current.  Galvanic  electricity  should  be  used  every  day:  fre- 
quently months  are  required  to  insure  a  cure,  in  conjunction  with  the 
medicinal  and  dietetic  treatment. 

Hirschsprung's  Disease  (Dilatation  of  the  Colon;  Megacolon). 

Dilatation  of  the  colon  and  hypertrophy  of  the  colon  may  be  due  to 
muscular  weakness  or  a  partial  defect  in  the  muscles  of  the  lower  portion 
of  the  large  intestine.  When  such  condition  exists  there  is  a  stagnation  of 
fascal  matter,  and  we  have  the  usual  products  of  fermentation  and  decom- 


INTESTINAL  COLIC.  273 

position.  The  latter  will  give  rise  to  considerable  flatulence  and  by  reason 
of  the  muscular  weakness  of  the  intestinal  walls  there  results  a  dilatation 
which  remains  permanent. 

There  are  two  prominent  symptoms  characteristic  of  this  disease :  first, 
obstinate  constipation,  in  some  cases  extending  over  many  days;  second, 
extreme  abdominal  distention. 

Some  of  these  cases  by  reason  of  the  stagnation  of  fa-cal  matter  will 
show  loss  of  appetite,  marked  irritability,  and  insomnia.  The  urine  usually 
contains  indican. 

The  diagnosis  depends  on  whether  or  not  the  condition  can  be  traced 
back  to  early  infancy.  It  is  important  to  differentiate  this  disease  from 
ovarian  tumor,  cirrhosis  of  the  liver,  or  abdominal  cysts.  The  diagnosis 
may  be  grave  if  colitis  ends  in  an  ulcerative  process. 

The  treatment  consists  in  abdominal  massage  and  mild,  stimulating 
laxatives.  It  is  important  to  correct  the  stagnation  of  fiecal  matter  by 
daily  injections  of  soap  water.  Surgical  aid,  such  as  resection  of  the  intes- 
tine, may  be  demanded  in  the  severer  forms  of  the  disease.  An  artificial 
anus  has  been  suggested;  this  must  be  considered,  however,  as  a  temporary 
benefit  only. 

Intestinal  Colic  (Intestinal  Neuralgia;  Enteralgia). 

Intestinal  colic  consists  of  pain  which  is  paroxysmal  in  character, 
located  in  the  bowel,  and  without  evidence  of  inflammation. 

Symptoms. — Colic  is  one  of  the  most  frequent  causes  of  crying  in 
children.  They  not  only  cry  loudly,  but  will  suddenly  shriek,  and  when 
put  to  sleep  will  awaken  with  a  sudden  start,  and  cry  loudly.  The  legs  are 
usually  flexed  or  they  will  move  their  legs  back  and  forth,  or  up  and  down. 
They  will  seem  to  bend  the  body  on  itself.  These  attacks  are  usually  asso- 
ciated with  constipation;  hence,  it  is  a  good  plan,  when  the  child  is  rest- 
less and  utters  a  painful  cry,  to  see  if  the  bowels  have  moved.  It  is  well 
known  that  this  colic  may  be  as  well  associated  with  diarrhcea.  The  origin 
of  all  colic  is  certainly  the  feeding.  When  dyspeptic  conditions,  arising 
from  undigested  particles  of  food  in  the  bowel,  exist,  then  fermentation, 
resulting  in  gas  formation,  is  the  result. 

Colic  is  frequently,  but  incorrectl)'',  known  by  the  terms  of  "meteoris- 
mus"  or  "tympanites,"  but  in  the  latter  conditions  the  abdomen  is  greatly 
distended,  and  there  is  a  permanent  enlargement  of  it.  Borborygmus 
(rumbling  sounds)  can  usually  be  made  out,  if  the  ear  is  applied  to  the 
abdomen.  The  vast  majority  of  cases  of  colic  have  their  seat  in  the 
intestine,  and  can  be  relieved  very  quickly. 

Causes. — ^^7"orms  (ascarides)  have  been  known  to  cause  colic.  When 
there  is  a  general  loss  of  tone  on  the  part  of  the  muscular  layers  in  the  walls 
of  the  intestine,  colic  will  frequently  result.    Jacobi  believes  that  colic  can 

18 


274  DISEASES  OF  THE  INTESTINES. 

be  caused  by  chronic  peritonitis  resulting  in  adhesions  or  local  changes  in 
the  walls  of  the  intestine  that  will  produce  local  contractions  or  dilatations. 

Excess  of  Sugar. — When  colic  is  caused  by  an  excess  of  sugar,  there 
will  be  considerable  eructations  of  gas,  and,  frequently,  small  quantities  of 
food  will  be  regurgitated. 

The  stools,  when  an  excess  of  sugar  is  given,  are  thin  and  greenish,- 
smell  very  acid,  and  usualljr  produce  a  reddened  excoriation  of  the  buttocks 
around  the  anus. 

When  children  show  a  tendency  to  the  development  of  gas  and  have 
constant  recurring  colic,  my  plan  is  to  discontinue  the  use  of  sugar  until 
such  time  as  this  fermentation  is  absent.  To  sweeten  the  food  I  use  small 
saccharine  tablets,  1  grain  being  ample  to  sweeten  1  pint  of  food.  When 
there  is  a  tendency  to  constipation,  it  is  possible  not  only  to  sweeten  the 
food,  but  also  to  modify  this  constipation  by  adding  a  teaspoonful  of  malt- 
extract  to  each  bottle.  One-half  teaspoonful  of  calcined  magnesia  added  to 
each  bottle  of  food  will  also  relieve  constipation. 

Excess  of  Protein. — A  careful  observation  of  the  stools  would  easily 
show  whether  the  albuminoids  are  in  excess,  for  they  are  usually  present 
in  the  form  of  curds.  This  condition  is  usually  associated  with  constipa- 
tion, and  the  indication  would  be  to  cut  down  the  quantity  of  protein 
administered. 

Undigested  curds  due  to  excess  of  protein  and  excessive  fats  are  a 
frequent  cause  of  colic.  Irregular  feeding,  too  frequent  or  over-feeding, 
are  the  commoner  causes.  The  majority  of  cases  of  colic  are  seen  in  bottle- 
fed  babies.  This  is  usually  due  to  milk  which  is  too  acid  or  superheated 
milk,  as  in  prolonged  sterilization.  In  the  latter  manner  of  treating  milk 
the  casein  is  rendered  very  difficult  to  digest,  and  frequently  results  in 
intestinal  fermentation,  causing  colic. 

Colic  in  Breast-fed  Babies. — -If  colostrum  continues  and  the  milk  does 
not  assume  normal  conditions,  colic  may  result.  Colic  is  frequently  seen 
during  menstruation  of  nursing  women.  Pregnancy  occurring  during  lac- 
tation usually  causes  colic. 

Differential  Diagnosis. — We  must  be  extremely  careful  to  exclude  the 
pain  of  intussusception,  the  pain  from  gall-stones,  the  pain  of  appendicitis, 
or  the  pain  of  a  strangulated  hernia.  The  absence  of  fever,  the  disappear- 
ance of  the  symptoms  by  the  regulation  of  the  diet,  the  flushing  of  the 
colon  to  remove  the  offending  cheesy  debris,  will  materially  aid  in  strength- 
ening the  diagnosis.  Sudden  cry  frequently  denotes  earache.  In  infants 
the  ears  should  be  examined  in  all  febrile  conditions. 

Infant  J.,  eleven  months  old,  bottle-fed,  cried  and  suffered  with  pain  from 
one  to  two  hours  after  taking  his  feeding.  The  temperature  was  101°  F.,  rarely 
higher.  The  infant  would  scream  for  a  few  minutes  at  a  time,  then  expel  flatus  per 
rectum,  and  be  apparently  relieved.  He  would  be  cheerful  and  play  for  a  short 
time,  when  another  paroxysm  of  pain  would  come  on  and  start  him  screaming  again, 


INTESTINAL  COLIC.  215 

until  flatus  was  expelled.  Relief  was  immediately  given  when  the  rectum  and 
colon  were  flushed  with  warm  water  temperature  105°  F.  to  which  several  ounces 
of  glycerine  had  been  added.  Antifermentatives,  such  as  rhubarb  and  soda  mixture, 
or  several  grains  of  calcined  magnesia,  invariably  relieved  the  child  and  prevented 
intestinal  fermentation. 

The  treatment  of  colic  is  simple  when  the  cause  is  known.  The  quick- 
est method  of  relieving  colic  is  to  give  an  enema  of  soap  and  w^ater  or  of 
warm  chamomile  tea.  Take  an  ounce  of  German  chamomile  flowers 
and  steep  them  in  a  quart  of  boiling  water  from  ten  to  fifteen  minutes, 
then  strain.  With  the  aid  of  a  rectal  tube  allow  1  or  2  pints  of 
chamomile  tea  at  a  temperature  of  100°  to  110°  F.  (no  hotter)  to  flow 
slowly  into  the  rectum  and  the  colon.  When  the  colon  is  thoroughly  flushed 
with  this  warm  tea,  and  emptied  of  its  faeces,  it  is  usual  for  the  attack  of 
colic  to  cease.  In  addition  to  washing  the  colon,  it  is  a  good  plan  to  apply 
a  small  bag  of  either  chamomile  flowers  or  slippery  elm  bark,  or  ground 
flaxseed  meal.  To  do  this,  I  make  a  bag  of  cheese-cloth  capable  of  holding 
from  1  to  2  ounces,  and  then  fill  it  with  one  of  the  above-mentioned  ingre- 
dients; sew  the  bag  shut  when  filled,  and  heat  it  before  applying  to  the 
abdomen.  Several  of  these  bags  can  be  made  and  kept  in  readiness,  so  that 
they  can  be  applied  quickly.  It  is  a  good  plan  to  have  one  heating  on  the 
stove  while  another  is  on  the  abdomen.    These  little  bags  are  very  soothing. 

Massage. — During  an  attack  of  colic  gentle  massage  with  warm  sweet- 
oil  or  melted  vaseline  or  lard  will  be  very  comforting  to  the  child.  The 
distended  abdomen  should  then  be  thoroughly  massaged  until  the  gas  is 
expelled  and  the  warm  applications  applied. 

Drug  Treatment. — If  the  colic  originated  from  a  fermentative  dys- 
pepsia, then  treatment  must  be  directed  to  the  stomach.  For  this  purpose 
antifermentatives,  like  the  mistura  rhei  et  sod^e,  should  be  given  in  doses  of 
i/o  to  1  teaspoonful,  diluted  with  water,  every  two  or  three  hours  until  there 
is  a  thorough  evacuation.  Five  to  10  grains  of  bismuth  or  i/2-grain  doses 
of  resorcin  will  also  be  found  useful.  Paregoric  in  doses  of  10  to  15  drops 
should  be  administered  to  children  of  six  months  or  older.  It  is  under- 
stood that  no  physiciaji  will  forget  the  danger  of  giving  repeated  doses  of 
paregoric  or  permitting  the  same  to  be  administered  by  incompetent  persons 
not  aware  of  the  dangers  of  the  drug  habit.  The  author  has  not  only  seen 
distinct  opium  poisoning  follow  the  use  of  paregoric,  but  has  also  had  occa- 
sion to  see  the  distinct  opium  habit  in  very  young  children.  This  was 
reported  by  me  in  a  paper  read  before  the  New  York  County  Medical 
Society,  January  22,  1894.^  For  an  infant  during  the  first  few  months,  it 
is  hardly  safe  to  give  more  than  5  drops  of  paregoric,  repeated  in  an  hour 
if  there  is  no  relief.  Another  drug  that  has  served  me  very  well  is  Hoff- 
mann's anodyne  in  doses  of  from  1  to  5  drbps,  repeated  in  an  hour  if 


^  Published  in  extcnso  in  the  Medical  Record  of  February  17,  1894. 


276  DISEASES  OF  THE  INTESTINES. 

necessary.  For  an  infant  up  to  two  months,  1  drop  per  dose;  from  two  to 
four  months,  2  drops  per  dose ;  four  to  six  months,  3  drops ;  six  to  nine 
months  and  until  1  year  of  age,  4  drops;  children  from  1  to  2  years,  5 
drops.  This  is  to  be  given  in  a  teaspoonful  of  sterilized  water.  Another 
valuable  drug,  and  one  that  is  to  be  given  cautiously,  and  in  the  same 
doses  as  Hoffmann's  anodyne,  is  spirits  of  chloroform;  never  should  more 
than  from  1  to  4  drops  be  given  to  a  child  up  to  1  year  of  age,  and  younger 
children  less  in  proportion.  I  cannot  favor  the  administration  of  nauseating 
or  foul-smelling  drugs,  such  as  asafoetida.  We  must  ti^  to  cater  to  an 
infant's  taste,  especially  so  when  in  pain. 

An  excellent  preparation  to  relieve  colic  is  calcined  magnesia,  or  milk 
of  magnesia,  made  by  Phillips.^  It  has  served  the  writer  very  well,  espe- 
cially in  young  infants,  where  acidity  was  prevalent.  A  half-teaspoon- 
ful  several  times  a  day  was  enough  in  some  cases,  while  others  required 
several  teaspoonfuls  during  the  day.  It  is  valuable  where  constipation 
exists,  and  can  be  added  to  the  bottle  of  food. 

Chronic  Intestinal  Indigestion  (Duodenal  Catarrh; 
Mucus  Disease)  . 

This  condition  is  always  associated  with  a  chronic  derangement  of  the 
stomach.  It  is  usually  a  functional  disturbance  and  is  one  of  the  most 
difficult  conditions  to  treat  ia  children. 

Etiology.— This  is  usually  obscure,  although  it  follows  exhaustive  dis- 
eases such  as  typhoid,  diphtheria,  or  other  infectious  diseases.  The  most 
frequent  cause  is  improper  food,  unsuited  for  the  age  and  development  of 
the  child. 

Symptoms. — As  a  rule,  gastro-enteritis  precedes  this  condition  for 
months,  in  each  and  every  case.  The  stool  shows  a  tendency  to  looseness 
and  mucus  is  found  covering  the  fgeces.  The  mucus  is  seen  in  shreds  and 
masses  at  times  covering  the  fsecal  matter.  Such  children  are  usually 
backward  in  development.  They  are  very  irritable,  tire  easily,  and  lose 
in  weight. 

As  a  rule,  the  abdomen  is  distended.  There  is  no  fever.  The  appetite 
varies  and  is  poor.  The  liver  does  not  functionate  properly,  and  in  some 
cases  very  little  bile  is  secreted,  giving  rise  to  clay-colored  stools.  The  skin 
is  dry. 


^PMllips's  Milk  of  Magnesia — Hydrated  Oxide  of  Magnesium  (MgHjOj). — A 
teaspoonful  of  Phillips's  Milk  of  Magnesia  is  equivalent  in  acid-neutralizing  power 
to  4  ounces  of  lime  water,  or  10  grains  of  sodium  bicarbonate.  It  will  neutralize 
nearly  twice  its  volume  of  lemon  juice.  Each  fluidounce  represents  24  grains  of 
magnesium  hydrate.  Dose:  From  a  teaspoonful  to  a  tablespoonful,  according  to 
age — increased  or  diminished  at  discretion.  Dilute  with  equal  quantity  or  more  of 
water.  .  . 


CHRONIC  INTESTINAL  INDIGESTION.  377 

Diagnosis. — The  only  condition  which  might  resemble  chronic  intes- 
tinal indigestion  is  general  tuberculosis.  The  absence  of  cough,  the  ab- 
sence of  fever,  and  the  absence  of  physical  signs  in  the  lungs  should  help 
to  exclude  tuberculosis.  The  diagnosis  will  be  more  readily  made  when 
previous  gastric  or  gastro-intestinal  derangements  are  taken  into  account. 

Prognosis. — This  is  usually  good,  even  though  the»e  attacks  may  ex- 
tend over  years.  If,  however,  rapid  emaciation  and  general  weakening  of 
the  heart  exists,  the  prognosis  becomes  grave. 

Treatment. — Dietetic  Treatment:  This  is  the  most  important  part 
of  the  treatment  and  requires  very  careful  consideration.  •  Excessive  fats 
and  sugars  should  be  avoided.  Light  meals  rather  than  heavy  should 
be  ordered.  Give  predigested  food  if  required.  Whey,  skimmed  milk, 
zoolak,  thin  cocoa,  chicken  broth,  beef  broth,  clam  broth,  soft-boiled  egg, 
fish,  oysters,  raw  scraped  steak,  apple  sauce,  baked  apple,  to  be  varied  with 
other  well-stewed  fruit,  should  be  given.  Avoid  all  fresh  bread.  Eusk 
(zwieback)  may  be  given.  Give  all  green  vegetables  in  season.  Avoid  all 
heavy  cakes,  pies,  and  puddings.  If  this  light  diet  is  continued  for  several 
months  great  improvement  will  be  noted.  The  ultimate  care  will  depend 
on  restricting  the  diet  to  nutritious  and  very  easily  digested  food. 

Medicinal  Treatment. — Give  nux  vomica,  1  to  3  drops,  three  times  a 
day,  before  meals.    Or : — 

Ijs  Acid,  hydroehlor.   dilut    1  ounce 

Five  minims  three  times  a  day,  after  meals. 

Pay  careful  attention  to  the  bowels;  give  a  laxative  if  necessary.  If 
severe  anaemia  exists  then  give : — 

IJ  Tr.  ferri  acet.  seth 1  ounce 

Ten  drops,  three  times  a  day.     One  hour  after  meals. 

This  has  been  found  to  be  the  best  form  of  iron  in  the  management  of 
this  condition. 

A  girl,  8  years  old,  was  breast-fed  in  infancy  and  appeared  apparently  healthy. 
Her  dentition,  walking,  and  talking  normally  developed  about  the  end  of  the  first 
year.  During  the  second  year  she  suffered  with  measles.  When  4  years  old  she 
had  an  attack  of  acute  milk  poisoning,  resulting  in  gastro-enteritis.  From  this 
time  on  she  has  not  been  in  good  health.  She  complained  of  headaches,  nausea, 
and  anorexia.  She  has  a  foul  breath,  and  is  very  anaemic.  She  does  not  seem  to 
thrive.  The  slightest  imprudence  in  eating  causes  gastric  symptoms.  Her  abdomen 
is  large  and  gas  is  frequently  expelled  per  rectum.  She  is  always  languid.  The 
temperature  is  normal,  the  pulse-rate  feeble;  it  usually  ranges  between  90  and 
100.  She  does  not  sleep  well,  talks  in  her  sleep  and  tosses  about.  Under  a  rigid 
diet,  excluding  pure  milk,  and  giving  diluted  milk,  whey,  thin  soups,  soft-boiled  eggs, 
and  fruit,  improvement  was  noted.  The  interval  of  feeding  was  restricted  to  five 
hours,  so  that  the  child  was  fed  three  times  a  day.  A  daily  movement  of  the  bowels 
was  insisted  upon.  One-half  teaspoonful  of  phosphate  of  soda  in  a  teacup  of  warm 
water  was  given  when  the  child  was  constipated.     Five  drops  of  acid  hydrochloric 


378  DISEASES  OF  THE  INTESTINES. 

dilute  was  given  three  times  a  day.     The  case  improved  and  the  child  is  in  a  good 
condition  to-day. 

Appendicitis. 

Appendicitis  is  an  inflammatory  condition  in  and  about  the  vermiform 
appendix.  The  size  of  the  appendix  varies  in  infancy.  Eibbert  gives  3.4 
centimeters  as  the  average  length,  whereas  Tojts  found  the  average  length 
.to  be  5  centimeters.  A  characteristic  of  the  appendix  in  infancy  is  the 
general  richness  in  follicles.  Fgecal  concretions  are  rarely  found  in  the 
appendix  of  infants  and  young  children;  this  may  be  due  to  the  fluid  diet. 
The  appendix  usually  contained  parasitic  ovi  and  mucus,  besides  undigested 
particles  of  food. 

Position  of  Appendix  in  Infancy. — The  appendix  is  situated  higher 
than  McBumey's  point.  ISTo  definite  rule  applies  to  the  position  during 
infancy.  It  may  be  found  pointing  downward  into  the  pelvis,  or  it  may 
be  directly  on  the  cecum  in  the  right  iliac  fossa,  or  it  may  point  upward. 
Cumston  reports  a  case  in  which  the-  tip  reached  the  right  lobe  of  the  liver. 
The  appendix  has  an  anatomical  similarity  with  the  tonsils.  Both  are 
composed  of  lymphatic  tissue,  and  are  adjacent  to  cavities  filled  with 
bacteria.  The  appendix  partakes  of  the  infiammatory  process  of  the  struc- 
ture with  which  it  is  intimately  associated. 

Bacteriology. — Macaigne  and  Cumston  found  that  cultures  of  the  bac- 
terium coli  obtained  from  stools  of  patients  suffering  with  appendicitis  were 
far  more  virulent  than  similar  cultures  from  healthy  subjects.  The  strep- 
tococcus in  milder  cases  produces  a  serious  catarrhal  process.  The  bacillus 
coli  is  the  commonest  organism  found  in  appendicitis,  although  the  strepto- 
coccus is  frequently  associated  with  it. 

Klecki^  found  that  pathogenic  bacteria  of  a  most  virulent  type  can 
penetrate  the  peritoneal  cavity.  This  penetration  is  either  during  perfora- 
tion or  through  the  lymph  spaces  of  the  damaged  intestinal  walls.  The 
bacteria  penetrating  into  the  mucosa  and  muscularis  may  produce  rapid 
necrosis  of  the  tissue  elements,  the  occurrence  of  perforation  depending 
upon  the  virulence  of  the  organism  present  and  to  some  extent  the  position 
of  the  appendix  in  which  gangrene  occurs.  In  infants  and  very  young 
children  inflammatory  processes  in  the  appendix  tend  to  progress  rapidly, 
that  is  to  say,  necrosis  of  the  mucosa  and  muscularis  occurs  promptly,  so 
that  the  bacteria  reach  the  serosa  quickly  before  protecting  adhesions  bave 
had  time  to  be  thrown  off.  For  this  reason  it  was  found  that  in  50  per 
cent,  of  cases  of  appendicitis  in  infants  and  young  children  extensive  peri- 
tonitis developed,  this  being  based  on  the  combined  statistics  of  Schiile, 
Rotter,  Lenander,  and  Sonnenburg. 

Death  is  frequently  caused  by  the  toxic  forms  of  appendicitis.     The 


^Annales  de  I'Institut  Pasteur,  vol.  lix,  p.  710. 


APPENDICITIS.  279 

absorption  of  the  bacterial  toxins  causes  the  body  to  be  overwhelmed  with 
this  poison.  A  thrombophlebitis  of  the  vessels  of  the  mucosa  takes  place; 
the  bacteria  become  attached  to  the  tlirombi,  liquefy  them,  and  thus  enter 
into  the  general  circulation,  producing  metastatic  foci  in  distinct  organs, 
such  as  the  lung,  kidney,  and  myocardium.  Thick,  inflammatory  adhesions 
always  denote  a  previous  inflammatory  process.  In  1867  Willard  Parker, 
in  the  Medical  Becord,  stated  that  necrosis  with  rapid  perforation  of  the 
appendix  was  quite  frequently  found  in  children. 

Pathology. — Catarrhal  Appendicitis:  In  this  form  the  walls  of  the 
appendix  are  found  thickened  and  hypera^mic.  The  lumen  of  the  tube  is 
filled  with  debris  of  inflammation.  If  this  inflamed  condition  continues, 
the  canal  may  become  ol)literated.  The  catarrhal  stage  frequently  ends  in 
resolution. 

Ulcerative  Appendicitis. — In  this  condition  the  process  involves  the 
muscular  coat,  because  the  mucous  and  submucous  tissues  have  been  de- 
stroyed.   The  ulcer  frequently  terminates  in  perforation. 

Gangrenous  Appendicitis. — In  this  condition,  also  known  as  intestinal 
appendicitis,  rapid  necrosis  of  all  the  coats  of  the  intestine  takes  place.  If 
a  fsecal  concretion  exists  and  the  ulcer  perforates,  an  infection  of  the  peri- 
toneal cavity  takes  place  from  the  virulent  bacteria.  This  is  usually  due  to 
a  thrombosis  of  the  artery  of  the  appendix  by  direct  extension  of  the  in- 
flammatory process  in  the  intestine.  By  this  means  the  entire  nutritive 
supply  to  the  organ  is  shut  off  and  a  rapidly  progressing  partial  or  total 
necrosis  results. 

Suppuration  frequently  follows  the  serous  exudation,  and  a  localized 
abscess  is  formed.  The  danger  of  such  an  abscess  consists  in  the  perforation 
taking  place  and  the  escape  of  the  pus  into  the  peritoneal  cavity,  setting  up 
a  diffuse  peritonitis. 

Causes. — Injury  to  this  region,  exposure  to  extreme  cold,  and  overin- 
dulgence in  purgatives  have  been  looked  upon  as  causative  factors.  Whether, 
foreign  Bodies,  such  as  seeds  or  hair  swallowed  by  mouth,  will  lodge  in  the 
appendix  and  cause  this  disease  is  doubted  by  many. 

Cases  of  helminthic  appendicitis  have  been  reported  in  which 
oxyurides  were  found  in  the  tip  of  the  appendix.  Pf oundler  and  Schlossman 
report  a  case  in  which  a  larger  number  of  ascarides  were  found. 

Symptoms  and  Diagnosis. — Muscular  rigidity  cannot  be  depended  upon 
as  a  symptom  in  children.  Every  young  child  resists  an  attempt  to  examine 
the  abdomen.  Cutaneous  h5'per8ssthesia  is  often  significant  of  appendicular 
inflammation.    A  sharp  pain  is  elicited  when  the  skin  is  lightly  touched. 

Palpation  of  the  appendix  is  always  somewhat  problematical.  We  may 
be  deceived  by  loops  of  the  intestine  in  that  region,  or  by  the  psoas  muscle. 
If  the  appendix  is  very  superficial,  and  if  it  is  distended  by  an  empyema, 
then  only  can  a  positive  diagnosis  be  made. 


280  DISEASES  OF  THE  INTESTINES. 

Pain  in  the  right  iliac  fossa  is  rarely  a  prominent  sj^mptom  in  children. 
Some  children  complain  of  an  acute  pain,  neuralgic  in  character,  in  the 
right  thigh.  An  abscess  may  appear  in  the  left  iliac  fossa  or  in  both 
fossae  at  the  same  time;  the  so-called  left-sided  appendicitis  is  a  left  iliac 
abscess. 

Subjective  symptoms  in  children  must  always  be  carefully  interpreted ; 
fear  will  frequently  prevent  complaining  when  an  operation  or  a  hospital 
has  been  spoken  of.  Localized  abscess  is  not  as  frequent  as  a  general 
peritonitis,  nor  can  we  make  out  a  tumor  as  promptly  in  children  as  in 
adults. 

Tense  abdominal  walls  with  distention  more  marked  on  the  right  side 
would  lead  us  to  suspect  an  inflammation  in  and  around  the  appendix.  The 
ceecal  region  can  be  easily  palpated  in  a  child.  If  it  is  impossible  to  properly 
examine  the  abdomen  and  rectum,  then  an  anaesthetic  should  be  given  and 
a  proper  examination  made. 

Eectal  examination  is  advisable  in  every  case  where  an  appendicitis  is 
suspected,  and  where  vomiting  and  diarrhoea  are  marked.  Palpable  resist- 
ance may  sometimes  be  made  out  in  the  right  pelvis.  If  pus  has  formed, 
a  tumor  surrounding  the  rectum  can  be  felt.  The  temperature  may  rise  as 
high  as  105°  in  some  cases  and  remain  as  low  as  101°  in  other  cases.  It  is 
only  at  the  beginning  of  an  acute  inflammatory  appendicitis  that  we  will 
have  a  rise  in  temperature.  Septic  cases  will  frequently  show  a  normal 
temperature;  therefore,  the  temperature  must  not  be  our  guide  as  to  the 
necessity  for  an  operation.  The  pulse  is  a  more  positive  guide  as  to  the 
presence  of  an  inflammatory  process;  it  also  offers  a  distinct  indication  for 
an  operation.  A  septic  appendix  will  show  its  presence  by  an  increased 
pulse ;  thus,  the  pulse  rate  in  an  acute  attack  may  vary  between  90  and  100, 
but  if  resistance  is  poor  the  pulse  rate  may  rise  to  110,  120,  or  130  beats 
per  minute,  and  the  prognosis  is  correspondingly  bad  in  such  a  case. 

Vomiting  is  an  early  symptom  and  one  that  occasions  considerable  dis- 
comfort. In  mild  forms  of  the  disease  vomiting  generally  subsides.  When 
peritonitis  complicates,  vomiting  usually  recurs.  Periodical  attacks  of 
vomiting,  so-called  cyclic  vomiting,  may  be  a  symptom  of  chronic  appendi- 
citis, with  interval  attacks. 

The  Bowels. — It  is  difficult  to  say  whetlier  constipation  or  diarrhoea 
more  often  accompanies  these  attacks.  I  have  seen  cases  in  which  diarrhoea 
continued  throughout  the  whole  attack,  so  that  my  suspicion  concerning 
typhoid  continued  until  the  localized  area  of  inflammation  formed.  Fre- 
quently the  symptoms  of  typhoid  are  so  well  marked  that  it  is  well  to  bear 
in  mind  the  possibility  of  this  disease.  In  other  cases  constipation  was 
noted  during  the  whole  course  of  the  disease. 

The  diagnosis  is  usually  not  very  difficult.  A  sudden  pain  localized  in 
the  right  iliac  fossa,  associated  with  gastric  or  intestinal  symptoms  and 


APPENDICITIS.  281 

fever,  should  render  the  diagnosis  easy.  I  rely  upon  the  examination  of 
the  blood  as  an  important  guide  in  determining  the  presence  of  pus  in  the 
system. 

■  We  must  not  mistake  appendicitis  for  an  abscess  in  the  right  ovary. 
The  same  can  be  differentiated  by  a  careful  vaginal  examination.  In  young 
girls,  where  this  is  very  difficult,  an  examination  can  be  made  with  greater 
ease  in  the  rectum.  By  means  of  bimanual  palpation  we  can  usually  dif- 
ferentiate the  same.  Acute  intestinal  obstruction  occurs  frequently  in  young 
children.  When  the  obstruction  is  due  to  an  intussusception,  bloody  dis- 
charges from  the  bowels  are  generally  present.  In  intussusception  the 
tumor  is  found  either  in  the  median  line  or  in  the  left  side,  whereas  in  ap- 
pendicitis it  occupies  the  right  iliac  fossa.  When  there  is  a  strangulated  gut 
due  to  a  volvulus  the  pain  is  not  localized.  In  this  form  of  obstruction  of 
the  bowel  there  is  usually  stercoraceous  vomiting. 

Hip-joint  disease  and  tuberculosis  might  possibly  be  mistaken  for  ap- 
pendicitis. There  are  a  great  many  cases  in  which  a  diagnosis  will  only  be 
positive  after  the  abdomen  has  been  opened. 

An  important  aid  in  the  diagnosis  is  the  examination  of  the  blood.  A 
marked  increase  in  the  leucocytes  occurs  in  appendicitis,  and  there  is  a 
marked  decrease,  leucopsenia,  in  typhoid  fever. 

Differential  Leucocyte  Count. — When  the  polynuclear  percentage  is 
70  to  80,  and  there  is  a  marked  leucocytosis,  we  should  suspect  pus.  This 
blood  examination  must  be  used  to  support  the  other  symptoms  indicating 
an  empyema,  an  appendicitis,  or  a  mastoid — in  fact,  any  suppurative 
condition. 

In  studying  the  leucocytes  by  the  daily  blood  examination  there  are 
certain  positive  indications.  Steadily  increasing  leucocjttosis  demands 
operation.  Steadily  decreasing  leucocytosis  is  a  favorable  symptom,  and 
contraindicates  the  necessity  for  an  operation. 

Course  and  Prognosis. — The  prognosis  depends  on  the  time  when  treat- 
ment is  commenced.  A  mild  case  of  appendicitis  may  resemble  colic  icitli 
a  slight  rise  of  temperature  and  pass  off  unnoticed.  If  these  attacks  recur 
our  suspicion  should  be  aroused  and  the  appendix  removed.  It  is  a  good 
plan  for  the  physician  to  call  the  surgeon  in  consultation  when  symptoms 
point  to  appendicitis.  Very  young  infants  do  not  hear  laparotomy  well, 
owing  to  the  shock  caused  thereby,  but  if  the  surgeon  operates  rapidly 
shock  is  greatly  lessened.  Cases  of  appendicitis  frequently  assume  a  chronic 
course.  Attacks  may  recur  at  intervals  of  weeks  or  months.  If  the  diag- 
nosis is  positive,  it  is  much  wiser  to  operate  during  the  intervals  of  health 
rather  than  run  the  risk  of  a  fatal  complication  such  as  peritonitis. 

Treatment. — First  and  foremost,  absolute  rest  in  bed.  Until  the  diag- 
nosis is  positive,  the  diet  should  be  restricted  to  strained  soups,  skimmed 


282  DISEASES  OF  THE  INTESTINES. 

milk,  and  weak  tea  for  thirst.  All  starchy  food  should  be  excluded;  hence 
neither  bread,  cereals,  nor  potatoes  should  be  permitted.  The  choice  be- 
tween hot-water  bags  and  ice-bags  depends  on  individual  experience.  An 
ice-bag  is  soothing  to  children.  The  application  of  several  leeches  in 'the 
early  stage  of  the  disease  will  sometimes  prove  beneficial.  It  is  of  impor- 
tance to  see  that  the  bowels  have  an  evacuation  once  or  twice  in  each 
twenty-four  hours.  While  it  is  desirable  to  have  an  evacuation,  no  active 
catharsis  should  be  prescribed.  Do  not  stir  up  the  abdomen  with  drugs,  as  it 
will  positively  do  harm.  To  relieve  the  constipation,  an  enema  of  1  pint  of 
soap  water  and  1  ounce  of  glycerine  will  evacuate  the  stagnant  faeces.  This 
enema  may  be  repeated  daily  until  the  acute  attack  has  subsided.  If  vomit- 
ing persists  cracked  ice  and  champagne  may  be  given.  The  value  of  opium 
is  disputed  by  many.  It  certainly  relieves  pain,  but  prevents  peristalsis.  My 
choice  has  been  codeine,  ^/jo  grain,  increased  to  ^/g  grain,  repeated  every 
hour,  depending  on  the  age  of  the  child,  until  the  pain  was  relieved. 

If  the  symptoms  continue  in  spite  of  the  above  treatment,  it  is  pos- 
sible that  medical  treatment  is  insufficient.  No  time  should  be  lost,  but 
prompt  surgical  relief  should  be  given. 

The  Time  to  Operate. — If  a  child  has  had  a  series  of  attacks  of  ap- 
pendicitis, then  it  is  well  to  operate  after  a  thorough  convalescence.  This 
operation  is  termed  the  "interval  operation.'^  During  the  interval  between 
the  attacks  the  physical  condition  of  the  patient  is  usually  better.  Great 
stress  should  be  laid  on  what  I  have  previously  mentioned  regarding  the 
blood  examination  with  especial  reference  to  the  leucocyte  count  and  the 
percentage  of  polynuclear  neutrophiles.  If  we  have  a  high  polynucleosis 
with  a  corresponding  leucocytosis,  then  an  operation  is  indicated. 

There  are  a  few  guides  which  may  be  of  assistance  when  the  blood  is 
examined  from  day  to  day.  Daily  variations  in  the  leucocyte  count  in  a 
suspicious  appendicitis,  are  doubtful.  If  the  leucoc5?tosis  is  stationary,  then 
the  abscess  may  be  walled  off.  If  the  leucocytosis  increases  it  means  a 
spreading  abscess.  When  the  leucocytosis  declines  from  day  to  day  it  means 
a  favorable  course  and  operation  may  be  postponed. 

If  a  general  peritonitis  is  present  operative  interference  must  not  be 
delayed.  It  is  in  this  class  of  cases  that  we  find  a  general  septic  process 
and  in  which,  in  addition  to  the  local  manifestations,  we  have  a  general 
systemic  infection. 

Pseudo-appendicitis. 

In  atony  of  the  bowel  we  frequently  have  impacted  faeces.  In  such 
cases  I  have  known  constipation  to  cause  colicky  pains  and  sudden  cramps, 
so  that  the  children  would  cry  out  suddenly.  Eelief  was  quickly  afforded 
by  a  high  soapsuds  enema,  which  brought  away  the  offending  masses  of 
hardened  faeces.     Fever  is  frequently  an  accompaniment  of  constipation. 


PSEUDO-APPENDICITIS.  383 

It  is  tlierefore  an  important  matter  to  exclude  all  otlier  factors  l)efore 
resorting  to  extreme  measures  and  advising  an  appendectomy.  The  fol- 
lowing two  cases  were  reported  by  me  in  Pediatrics,  Vol.  XllI,  Xo.  1, 
1902  :— 

Case  I.^Maggie  W.,  10  years  old,  was  perfectly  liealthy  until  the  time  of  her 
present  illness.  She  was  suddenly  attacked  with  pain,  which  was  localized  in  the  right 
hypochondriac  region;  the  pain  was  very  acute  and  was  increased  on  pressure;  the 
abdomen  was  distended  and  quite  tympanitic  on  percussion;  there  was  a  marked 
dullness  in  the  ileocaecal  region ;  there  was  an  intense  vomiting,  the  vomit  containin*^ 
particles  of  food  along  with  mucus  and  bile  and  had  a  very  offensive  odor.  Tha 
child  vomited  several  times  in  one  liour  and  seemed  to  vomit  whenever  the  pain  was 
most  acute.  The  mother  stated  tliat  the  child  had  a  regular  movement  of  the  bowels 
once  in  twenty-four  hours,  that  she  had  had  a  movement  tliat  day  and  that  her 
appetite  liad  been  quite  good.  She  was  a  very  strong  and  well-nourished  child  with 
no  evidence  of  organic  disease;  there  was  no  hysterical  element;  the  child  complained 
of  no  other  pain  but  that  directed  to  this  abdominal  condition ;  there  was  a  history 
of  improper  diet  but  no  history  of  traumatism;  the  heart-sounds  were  normal;  no 
murmurs  were  audible,  the  lungs  were  normal  on  percussion  and  auscultation;  the 
liver  did  not  seem  to  be  enlarged;  the  spleen  was  jjalpable  but  not  enlarged;  the 
temperature  was  104°  F.,  taken  in  the  rectum;    pulse,  110;    respiration,  20. 

When  first  seen  an  ice-bag  had  been  applied  over  the  most  tender  spot  in  the 
abdomen.  Codeine  in  Vcrgrain  doses  had  been  administered  and  a  liquid  diet  pre- 
scribed. The  child  was  first  seen  by  me  abo\it  twenty  hours  after  the  commencement 
of  her  illness  with  the  above-named  conditions.  As  this  case  had  been  seen  by 
another  colleague  I  was  requested  to  meet  him  in  consultation.  The  diagnosis  of 
perityphlitic  abscess  had  been  made  and  an  operation  advised.  The  diagnosis  was 
not  so  positive  owing  to  the  history  of  overeating.  The  child  partook  of  many 
kinds  of  cake  and  pastries  while  celebrating  a  birthday,  and  an  overloaded  stomach 
appeared  most  plausible.  Hence  an  acute  catarrhal  gastritis  was  diagnosed.  The 
pain  and  tenderness  in  the  abdomen  was  ascribed  to  a  colicky  condition,  resulting 
from  fermentative  processes  in  the  stomach  and  extending  into  the  intestine.  The 
indication  was  to  cleanse  the  stomach  and  bowels  as  rapidly  as  possible  and  thus 
remove  the  toxsemic  condition  which  existed.  Meanwhile  an  operation  was  not  con- 
sidered until  after  the  above  measures  were  used. 

The  urine  was  examined  and  sliowed  a  lai'ge  excess  of  phosphates;  no  albumin, 
no  sugar,  no  casts,  no  diazo-reaction ;  hence  we  e.xcluded  typhoid.  There  was  a  very 
strong  indican  reaction  and  this  latter  strengthened  the  diagnosis  of  fermentation 
due  to  intestinal  putrefaction. 

The  Treatment. — I  suggested  the  use  of  a  very  high  enema  with  a  long  tube 
reaching  into  the  colon;  the  enema  consisting  of  1  pint  of  glycerine  diluted  with  2 
pints  of  warm  water;  the  temperature  of  the  same  was  102°  F.  The  enema  was 
very  effectvial  and  brought  away  .a  large  amount  of  gas.  The  t?mperature  which, 
as  above  stated,  was  104°  F.,  fell  to  102°  F.  within  one  hour  and  gradually  returned 
to  normal  in  twelve  hours,  although  no  other  antipyretic  measure  was  used.  Small 
doses  of  citrate  of  juagnesia  were  ordered,  a  tablespoonful  hourly,  to  quench  thirst 
and  at  the  same  time  to  have  a  slight  laxative  effect.  A  liquid  diet  was  continued, 
and  thirty-six  hours  after  the  above  remedies  were  ordered  the  child  was  in  a 
normal  condition. 

Case  II. — A  female  child,  about  10  years  old,  was  seen  by  me  through  the 
courtesy  of  Dr.  L.  Harris,  with  severe  abdominal   symptoms.     The  most  prominent 


284  DISEASES  OF  THE  INTESTINES. 

symptom  was  an  intense  pain  localized  in  the  right  hypochondriac  region,  more  espe- 
cially in  the  ileocsecal  region.  There  was  a  marked  distention  of  the  whole  abdomen; 
there  was  constipation  and  vomiting;  the  temperature  ranged  between  102°  and 
103°  F. ;  the  pulse,  which  was  110,  rose  to  120.  The  child  complained  of  an  intense 
headache;  in  the  beginning  she  also  had  a  chill.  The  history,  as  given  to  me  by 
Dr.  Harris,  was  that  the  child  had  fallen  from  a  fence  on  which  she  was  standing,  in 
tlie  yard,  a  distance  of  about  three  feet.  He  believed  that  she  had  injured  herself. 
The  doctor's  diagnosis  was  peritonitis  from  traumatism.  In  this  diagnosis  I  con- 
curred. There  was  no  distinct  localized  area  of  pain,  but  rather  a  diffused  area  of 
pain  extending  over  the  whole  of  the  abdomen,  Avhich  was  intensified  in  the  immediate 
locality  of  the  injury.  There  Avere  no  chills;  there  were  no  rigors;  the  tempera- 
ture rose  gradually;  there  was  no  evidence  of  suppuration  and  none  suspected. 
The  child  Avas  placed  on  a  carefully  restricted  liquid  diet,  consisting  of  broth,  soup, 
strained  gruel,  milk,  egg  albumin  in  various  forms  and  in  addition  thereto  opium  in 
the  form  of  deodorized  tincture  was  given  to  alleviate  pain.  Attention  was  directed 
to  the  bowel  and  an  enema,  was  given  to  flush  the  rectum  and  colon  and  relieve 
accumulated  fseces. 

Another  colleague  saw  the  child  and  diagnosed  appendicitis,  and  suggested 
immediate  operative  treatment.  I  Avas  again  requested  by  the  attending  physician, 
Dr.  Harris,  to  meet  Avith  this  other  colleague,  and  as  a  result,  Ave  decided  not  to 
have  operative  interference  until  Ave  Avere  satisfied  that  we  were  dealing  with  a  puru- 
lent case.  Palliative  measures  were  used,  such  as  ice,  locally.  In  addition  thereto 
the  most  absolute  rest  Avas  enjoined,  and  the  child  made  a  brilliant  recovery  without 
an  operation.  We  Avere  satisfied  that  Ave  Avere  dealing  Avith  a  traumatic  peritonitis 
in  which  the  local  area  of  pain  Avas  due  to  the  traumatism. 

A  careful  review  of  tlie  above  two  cases  will  show  that  when  the  diag- 
nosis of  appendicitis  is  made  b}^  a  process  of  exclusion  then  greater  care 
should  be  exercised  before  resorting  to  extreme  measures. 

In  the  first  case  the  high  temperature  and  the  suddenness  of  the 
attack  certainly  showed  marked  symptoms  pointing  toward  appendicitis. 
The  high  temperature  was  due '  to  the  toxsemic  condition  resulting  from 
impacted  faeces.  The  pain  was  an  enteralgia  due  to  a  distended  gut  filled 
with  gas.  Such  colicky  conditions  are  so  frequent  in  young  infants  that 
we  could  operate  very  frequently  if  the  diagnosis  of  appendicitis  were  made 
every  time  an  infant  screams  Avith  pain.  The  cases  above  reported  are  very 
interesting  as  shoAving  that  cases  will  frequently  have  symptoms  resembling 
perityphlitis  or  perityphlitic  abscess,  so  that  a  differential  diagnosis  will  be 
very  hard  to  make.  Not  infrequently  cases  of  appendicitis  will  be  over- 
looked, and  when  such  is  the  case,  if  they  are  of  the  catarrhal  type,  no 
harm  will  ensue  therefrom.  On  the  other  hand,  I  must  not  be  understood 
as  disparaging  the  idea  that  no  case  of  appendicitis  requires  an  ojDeration, 
but  my  object  in  calling  attention  to  these  two  cases  is  to  offer  a  plea  that 
before  a  case  of  supposed  appendicitis  is  subjected  to  an  operation,  that  we 
should  be  sure  that  all  other  conditions,  such  as  impacted  faeces,  as  in  my 
first  case,  and  other  allied  conditions  have  been  excluded  in  the  diagnosis. 


INTrSSlS(  'lOI'TION.  2<S5 

AUTU-iXTUXlCATlOX. 

In  very  young  infants  auto-intoxication  of  the  intestines  is  caused  hy 
protein  or  fatty  indigestion  and  fermentation,  and  is  one  of  the  most  fre- 
quent causes  of  higli  fever. 

Too  frequent  feeding,  or  tlie  feeding  of  food  containing  a  high  fat  or 
excessive  protein  suitable  for  the  infant,  provokes  dyspeptic  indigestion. 
From  this  indigestion  we  have  fever  and  the  products  of  decomposition 
resulting  in  toxasmia.  Jf  tliis  toxaemia  continues  convulsions  frequently 
follow. 

Another  common  form  of  auto-intoxication  met  with  is  due  to  stagnant 
faeces.  An  impacted  stool,  especially  if  atony  of  the  intestine  exists  will 
frequently  cause  a  rise  of  temperature  and  give  marked  systemic  disturb- 
ances such  as  loss  of  appetite  and  headache.  The  abdomen  is  distended, 
notably  the  transverse  colon.  The  urine  is  high  colored  and.  gives  an 
indican  reaction. 

The  treatment  consists  in  relieving  the  bowels  by  an  injection  of  one 
pint  of  soap  water.  Internally  5  grains  of  compound  jalap  jDowder  with  2 
grains  of  calomel  should  be  given.  Milk  should  be  stopped.  Whey  or 
thin  broths  should  be  given  for  at  least  twenty-four  hours.  Water  liberally 
is  required. 

lNTUSSUSCEPTIO:Nr. 

The  most  frequent  form  of  obstruction  of  the  bowel  is  that  known  as 
intussusception,  or  invagination  of  the  bowel. 

Intussusception  involves  three  layers  of  the  bowel,  each  laver  consist- 
ing of  all  the  intestinal  coats:  First,  the  outer  layer  is  knoA^n  as  the  intus- 
suscipiens,  the  sheath  or  receiving  layer;  second,  the  internal  is  known 
as  the  entering  layer  which,  together  with  the  third,  the  middle  or  return- 
ing layer,  constitutes  the  invaginated  part  known  as  the  intussusceptum. 

The  clinical  records  show  that  al)out  one-half  of  all  cases  occur  at  the 
junction  of  the  small  and  large  intestine. 

When  the  ileum  becomes  invaginated  in  the  .colon,  the  condition 
is  termed  ileo-colic  intussusception. 

In  less  than  one-third  of  all  cases  invagination  takes  place  in  the  small 
intestine.  This  is  known  as  ileal  or  jejunal  intussusception.  When  this 
invagination  takes  place  only  in  the  large  intestine  it  is  called  colic  intus- 
susception. 

This  usually  commences  at  the  ileo-ca^cal  valve  and  extends  down- 
ward. It  is  felt  as  a  tumor  much  larger  than  the  swelling  found  in  appen- 
dicitis. 

Intussusception  usuaUij  causes  a  recession  of  the  ahdoiuen  from  the 
S'ide  of  the  ccecum,  while  appendicitis,  if  it  does  anything,  will  at  least 
prevent  recession  of  the  ahdominal  walls  at  this  point. 


286  DISEASES  OP  THE  INTESTINES. 

Symptoms  and  Diagnosis. — Nausea  and  vomiting  are  among  the  earliest 
symptoms.  Later  in  the  disease  the  vomit  becomes  fsecal  (so-called  ster- 
coraceous  vomit)  in  character.  The  child  has  pain;  assumes  the  dorsal 
position  with  the  thighs  drawn  up  on  the  abdomen.  The  pain  appears  in 
paroxysms,  accompanied  with  a  discharge  of  blood  and  mucus.  Eectal 
tenesmus  also  is  present.  The  temperature  ranges  between  101°  and  103°  F. 
The  pulse  from  120  to  150  per  minute. 

Cases  that  give  a  clear  history  of  intestinal  obstruction  with  no  stool 
passing,  and  vomiting  caused  by  such  obstruction,  offer  a  good  prognosis  if 
operated  early.  Continued  vomiting  of  food  will  cause  exhaustion  and  rob 
the  infant  of  the  vitality  necessary  to  undergo  the  shock  caused  by  the 
operation. 

The  following  case  will  illustrate  intussusception  as  met  with  in  gen- 
eral practice.    The  history  was  as  follows : — 

Infant  B.,  five  months  old,  had  vomited  for  some  time ;  was  constipated,  having 
had  no  stool  for  several  days.  The  temperature  was  about  normal;  the  abdomen 
was  distended.  The  child  was  breast-fed.  The  breast  was  discontinued  for  a  short 
time  and  barley  water  substituted  to  relieve  the  vomiting. 


ANUS. 


Fig.  81. — Mechanism  of  Intussusception  (Treves).  The  sheath  at  A 
passes  to  B,  then  to  C.  The  lower  part  of  the  intestine  is  drawn  over  the 
upper  instead  of  the  upper  crowded  into  the  lower.  For  a  fuller  description 
see  Treves's  "Intestinal  Obstruction,"  London,  1884. 

Through  courtesy  of  Dr.  A.  E.  Isaacs,  of  this  city,  I  saw  the  child  several  times 
in  consultation. 

The  vomiting  continued  in  spite  of  the  withdrawal  of  the  breast-milk.  Par- 
oxysms of  pain  constantly  recurring.  Infant  screaming.  Repeated  enemas  did  not 
result  in  emptying  the  bowels.  Calomel  had  been  given  in  both  large  and  small  doses 
with  no  satisfactory  result.  In  addition  thereto  cathartics  had  been  given.  The 
vomiting  persisted;  at  the  same  time  the  distention  in  the  abdomen  continued.  The 
diagnosis  intussusception  was  made  and  an  operation  suggested.  The  family  objected 
to  an  operation  and  palliative  measures  were  used.  The  child  died  several  days 
later.     The  symptoms  which  were  most  marked  in  this  case  were: — 

1.  Continued  vomiting. 

2.  Fsecal  impaction,  the  gut  being  so  obstructed  that  no  faeces  passed  in  more 
than  ten  days,  though  flatus  would  occasionally  pass. 

3.  During  the  first  two  or  three  days  not  only  was  clear  blood  passed  per 
rectum,  but  large  masses  of  jelly-like  mucus  tinged  ivith  blood  were  frequently  ex- 
pelled from  the  rectum  until  the  end. 

4.  The  distended  belly,  the  abdomen  abnormally  distended,  and  very  tympanitic 
on  percussion. 

5.  The  absence  of  all  inflammatory  symptoms  such  as  rise  of  temperature  until 
two  days  before  the  death  of  the  patient,  when  the  temperature  rose  to  101°  F.  and 
the  pulse  rose  to  160. 


PLATE  YIII 


Intussusception.     (Courtesy  of  Dr.  Reu.) 


PLATE  TX 


Intussusception.     (Courtesy  of  Dr.  Reu.) 


INTUSSUSCErTION.  ^87 

6.  Continued  crying;  the  child  with  rare  exceptions  showed  evidences  of  pain. 

There  was  no  positive  etiological  factor  in  this  case,  as  there  were  two  other 
healthy  children  in  this  family;  the  father  and  mother  were  in  apparent  good 
health.  There  was  no  evidence  of  traumatism  nor  anything  that  could  be  connected 
with  the  cause  of  this  condition.  The  mother  stated  that  for  a  period  of  two  months 
before  the  appearance  of  this  condition  she  had  given  a  patent  cathartic  every  day, 
as  she  thought,  with  advantage.  Whether  or  no  this  drug  had  anything  to  do  with 
this  condition  it  is  difficult  to  state.  The  presvunption  is,  however,  that  the  con- 
tinued effect  of  giving  cathartics  was  indirectly  the  cause. 

In  the  above-reported  case  an  operation  was  refused  and  the  child 
died.    The  chances  Avere  in  its  favor: — - 

1.  Because  it  was  a  well-developed  and  well-nourislied  baljy. 

2.  Because  it  was  breast-fed. 

3.  Because  the  diagnosis  was  made  very  early  in  the  disease. 

4.  Because  the  heart's  action  was  very  good,  and  no  chronic  or  infec- 
tious disease  existed. 

In  1870  Pilz^  reported  94  cases  under  1  year — mortality,  84  per  cent. 
From  1870  to  1891  135  cases,  under  1  year,  gave  mortality  of  59  per  cent. 

The  reduction  in  percentage  of  mortality  in  recent  years  is  evidently 
due  to  modern  aseptic  surgery.  Whereas  formerly  recovery  depended  on 
sloughing,  to-day  laparotomy  is  the  rule. 

Two  interesting  clinical  points  which  I  have  made  use  of  are  given  by 
Caille:— 

1.  Try  to  reduce  the  obstruction  by  non-operative  means — injections 
of  oil — the  child  in  an  inverted  position  following  the  injection;  gentle 
manipulation  of  the  abdomen. 

2.  In  percussing  the  abdomen  there  will  generally  be  found  at  the 
site  of  the  obstruction  a  very  tympanitic  area  adjoining  a  dull  area.  By 
carefully  noting  this  point  the  surgeon  has  an  important  landmark  for  his 
guidance  in  performing  the  operation. 

Prognosis. — Without  operation  the  prognosis  is  exceedingly  bad.  The 
earlier  the  operation,  the  better  the  result.  In  some  cases  Nature  relieves 
the  invagination  and  a  slough  will  separate.  This  is,  however,  a  rare  con- 
dition. 

Treatment. — When  the  diagnosis  is  established  no  time  should  be  lost. 
Inflation  of  the  lotoel  with  air  or  hydrogen  tlirough  a  long  rubber  tube 
has  been  recommended.  When  this  is  not  successful  the  child  may  be  in- 
verted and  gentle  manipulation  of  the  abdomen  may  be  attempted. 

Injections  may  be  given  with  or  without  ansesthesia.  The  baby  is 
turned  on  its  belly;  the  hips  are  raised  by  gently  supporting  the  abdomen 
on  a  soft  pillow.  The  mouth  and  nose,  being  the  lowest  part  of  the  body, 
must  be  protected.  The  baby  is  then  anaesthetized  with  chloroform,  and 
warm  water  is  poured  into  the  rectum  with  but  little  pressure,  from  a 


Jahrbuch  fiir  Kinderheilkunde.     Bd.  iii,  p.  6. 


288 


DISEASES  OP  THE  INTESTINES. 


height  not  exceeding  three  feet.  The  injection  is  frequently  intermitted, 
while  the  anus  is  closed  with  a  cotton  plug  held  by  the  finger.  At  the 
same  time  the  abdomen,  in  the  direction  from  below  upward,  is  gently 
kneaded  and  its  contents  moved  about. 

Unless  this  proves  successful  no  time  should  be  lost  and  an  abdominal 
operation  should  be  performed. 

Although  surgical  interference  offers  the  best  means  of  treatment,  we 
should  note  the  condition  of  the  child  at  the  time  of  operation,  and  con- 
sider the  result  of  shock  and  hgemorrhage  in  estimating  the  therapeutic 
result.  No  cathartics  should  be  given  after  the  operation,  but  the  bowels 
should  be  confined  by  administering  a ^  small  dose  of  opium.     Stimulation 


Fig.  82. — Umbilical  Hernia.     The  result  of  violent  paroxysms  of 
whooping-cough.      (Original.) 


will  be  urgently  demanded;  hence  whisky  or  iced  champagne  should  be 
given  db  libitum.  It  is  well  to  remember  that  very  young  children  do 
not  offer  good  resistance  to  the  shock  of  an  abdominal  section.  Fully  50 
per  cent,  of  cases  seen  by  me  were  fatal.  The  details  of  an  operation  for 
intussusception  are  those  of  aseptic  surgery,  for  which  my  readers  are 
referred  to  the  special  books  on  surgery.  Dr.  John  P.  Erdman,  of  New 
York  City,  has  reported  a  series  of  successful  operations  in  very  young 
children. 

Umbilical  Hernia.^ 

This  condition  is  frequently  seen  in  both  male  and  female  children. 
It  is  more  often  seen  in  the  female. 

Causes. — It  is  usually  found  in  children  with  flabby  muscles  such  as 
rachitic  and  atrophied  cases.  Severe  abdominal  strain  during  the  parox- 
ysms of  whooping-cough  or  in  continued  constipation  frequently  results 


^  For  Inguinal  Hernia,  see  chapter  on  "Diseases  of  the  Genito-Urinary  Tract." 


PLATE  X 


Cestodes  (Tape-worms).  1,  Ttenia  saginata.  A,  Head  of  taenia  sagi- 
nata.  2,  Dorsal  view  of  the  head.  3,  Apex  view  of  head,  showing  depres- 
sion in  center.  .),  Isolated,  elongated  segments.  5,  Bothriocephalus  latus. 
6,  Ripe  segments  of  taenia  saginata.  B,  showing  location  of  sexual  organs. 
7,  Half-developed  segments  of  taenia  saginata.  Illustrations  drawn  from 
specimens.      ( Original. ) 


TAPEWORM. 


289 


in  umbilical  hernia.  The  tumor  may  be  from  one-half  to  one  inch  wide, 
and  the  same  also  in  length. 

Treatment. — Preventive  Treatment:  After  the  umbilical  cord  has 
separated,  the  usual  flannel  binder  may  be  used  to  lend  support  to  the 
abdomen  for  the  first  two  or  three  months. 

Mechanical  Treatment. — A  pad  of  absorbent  cotton  into  which  a  thick 
piece  of  cork  or  a  wooden  button  the  size  of  a  25-cent-piece  is  wrapped, 
should  be  snugly  pressed  over  the  protruding  part  and  secured  by  thick 
straps  of  zinc  oxide  plaster.  This  dressing  should  be  renewed  every  four 
or  five  days.    The  treatment  must  be  continued  for  several  months. 

A  truss  consisting  of  a  rubber  pad  and  a  belt  to  pass  around  the 
body  should  be  applied  so  that  it  cannot  slip  and  has  enough  pressure  to 
keep  the  hernia  in  place. 


Fig.  83. — Umbilical  Hernia  Truss. 


Tapeworm  (Cestodes). 

The  tapeworm  enters  the  body  by  food  containing  the  larvae.  Sev- 
eral varieties  are  met  with.  When  the  worm  is  fully  developed  it  consists 
of  rectangular  segments  or  pieces.  These  segments  are  also  called  pro- 
glottides.   The  head  and  neck  of  the  worm  are  called  scolex. 

The  eggs  (larvas)  of  the  taenia  solium  are  found  in  pork;  taenia 
mediocanellata,  in  beef;  bothriocephalus  latus,  in  fish;  t^nia  cucumerina, 
in  dogs  and  cats. 

Development  of  the  Worm. — A  worm  develops  in  about  three  months. 
When  the  terminal  segments  are  matur.e  they  separate  and  are  discharged 
in  the  stool.  As  each  segment  contains  both  male  and  female  organs,  each 
one  is  capable  of  regenerating  a  whole  worm.  For  this  very  reason  the 
treatment  of  a  tapeworm  will  never  be  successful  until  the  head  and  every 
segment,  has  been  expelled.  Tapeworms  are  estimated  to  live  from  ten  to 
twenty,  and  possibly,  thirty  years. 

The  beef  tapeworm  is  the  most  frequent  found  in  children.  It  has 
four  suckers,  a  square  head,  and  no  hooks.  Eaw  meat  may  contain  the 
cysticerci. 

The  pork  tapeworm  is  the  rarest  found  in  children.  The  head  has 
four  suckers,  surrounding  which  there  is  a-  circle  of  about  twenty-six  hooks. 
The  length  of  the  worm  varies  from  ten  to  fifty  feet.  Nursing  children 
are  exempt  from  tapeworm. 

19 


290  DISEASES  OF  THE  INTESTINES.  . 

Symptoms. — In  children  between  2  and  4  years  of  age  subjective 
symptoms  are  difficult  to  interpret.  In  older  children  we  will  notice  at- 
tacks simulating  colic  associated  with  fairly  good  movements  of  the 
bowels.  There  is  restlessness  at  night  and  marked  nervous  irritability  by 
day.  The  breath  is  foul  and  the  child  presents  evidences  of  marked 
anaemia.  In  spite  of  an  abnormally  large  appetite  the  body  wastes  and 
the  child  is  believed  to  suffer  with  some  latent  form  of  tuberculosis. 

Diagnosis. — The  diagnosis  is  positive  only  when  segments  of  the  worm 
are  found.  The  absence  of  cough  or  pulmonary  symptoms  will  usually  aid 
in  excluding  tuberculosis.  At  times  several  weeks  will  pass  before  a  posi- 
tive diagnosis  can  be  made. 

Prognosis. — The  prognosis  is  usually  good.  It  is  simply  necessary  to 
use  radical  treatment  to  dislodge  and  sicken  the  worm  and  then  expel  it. 

Treatment. — ^The  tsenicide  should  be  given  after  fasting  and  followed 
in  an  hour  by  a  cathartic  to  carry  off  the  worm.  The  best  tsenicides  are 
pomegranate  or.  its  alkaloid,  pelletierine ;  filix  mas;  kousso;  pumpkin- 
seed,  and  turpentine. 

IJ  Oleores.  filis  mas    1%  drachms 

Chloroform 10       drops 

Syr.  ginger  q.  s.  ad     1       ounce 

M.     Sig. :     Divide  into  two  parts.    Take  on  empty  stomach,  half -hour  apart. 

For  a  child  ten  years  old,  younger  children  one-half  the  dose. 

^  Tannate  of  pelletierine %  grain 

Sig.:     For  a  child  3  to  5  years  old  (T.  M.  Rotch). 

IJ  Olei  terebinthinse 1  fluidrachm 

Olei  ricini  %  ounce 

M.     Sig.:     Take  it  in  one  dose  (Farqhuarson). 

Since  entire  expulsion  of  the  tapeworm  is  effected  with  difficulty, 
preparatory  treatment  for  about  forty-eight  hours  should  be  employed 
before  the  vermifuge  is  administered.  During  this  time  the  patient  should 
take  a  mild  purgative  once  or  twice,  and  such  food  in  moderate  quantity 
should  be  allowed  as  leaves  little  residuum,  as  beef-tea,  etc.,  with  some 
stimulant  if  the  patient  feels  exhausted.  There  are  three  articles  of  food 
which  experience  has  shown  to  be  especially  useful  in  this  preparatory 
treatment,  perhaps  from  a  sickening  effect  which  they  produce  upon  the 
worm,  namely,  salt  herrings,  onions,  and  garlic.  This  may,  therefore,  be 
taken  as  food  in  the  twelve  or  eighteen  hours  preceding  the  employment 
of  the  vermifuge,  which  it  is  ordinarily  most  convenient  to  administer  in 
the  morning. 

ASCARIS  LUMBRICOIDES    (EOUND  WORM). 

This' worm  is  a  reddish  or  yellowish  round  worm,  usually  from  5  tp 
10  inches  long.    The  male  worm  is  smaller  than  the  female.     This  worm 


ASCARIS  LUMBRICOIDES.  291 

inhabits  the  small  intestines.  It  is  seldom  found  solitary,  but  usually  4 
to  10  may  be  present.  Some  authors  state  that  as  many  as  200  and  300 
have  been  found  at  one  time.  The  worm  is  usually  found  in  children 
between  the  second  and  tenth  years.  It  is  never  found  in  nurslings.  These 
worms  will  wander  from  the  small  intestines  into  the  stomach  and  irritate 
the  gastric  mucosa.    They  are  frequently  expelled  by  vomiting. 

A  child  4  years  old  was  seen  by  me  during  my  service  at  the  Willard  Parker 
Hospital  in  the  fall  of  1903.  The  child  had  pharyngeal  and  tonsillar  diphtheria.  It 
was  a  septic  type  of  diphtheria.  The  child  vomited  a  round  worm  about  6  inches 
long  on  the  second  day  after  admission.  On  the  third  day  another  vporm  about  5 
inches  long  was  also  ejected  by  vomiting.  There  were  no  symptoms  pointing  to  the 
presence  of  these  round  worms. 

Some  authors  report  worms  wandering  into  the  nose  and  also  into 
the  middle  ear.  A  worm  entering  the  larynx  has  produced  fatal  asphyxia. 
Another  author  reports  jaundice  due  to  worms  entering  the  common  bile 
duct.  Worms  have  been  known  to  produce  hepatic  abscesses.  They  have 
been  found  in  the  vermiform  appendix.  These  worms  appear  most  fre- 
quently in  the  stools.    They  have  been  found  in  umbilical  abscesses. 

Symptoms. — Very  indefinite  symptoms  can  be  ascribed  to  these  round 
worms.  Irritation,  such  as  restlessness  at  night,  grinding  of  teeth,  picking 
the  nose,  and  scratching  the  anus.  Abdominal  symptoms,  such  as  colic, 
diarrhoea,  and  tympanites,  are  frequent.  This  clinical  picture  must  not 
be  presumed  to  be  present  in  all  cases.  Not  infrequently  symptoms  of 
meningitis  will  be  mistaken  for  worms.  Be  sure  to  exclude  all  other  con- 
ditions before  expressing  a  positive  opinion.  Nervous  symptoms,  such  as 
hysteria,  vertigo,  and  epileptiform  convulsions,  have  been  noted  while 
worms  existed.  As  these  conditions  disappeared  when  the  worms  were 
expelled,  it  is  but  fair  to  presume  that  they  were  indirectly  the  cause  of 
these  nervous  manifestations. 

Diagnosis. — A  positive  diagnosis  can  only  be  made  if  the  round  worms 
are  discharged  from  the  body  or  if  the  ova  are  discovered  in  the  stool.  The 
microscopical  examination,  therefore,  is  very  valuable  and  should  always 
be  made  when  in  doubt.  If  the  ova  are  still  found  in  the  stool  after  one 
or  two  worms  have  been  expelled,  then  more  worms  should  be  suspected. 

Prognosis. — The  prognosis  is  always  good,  but  the  child  must  be  kept 
under  constant  observation  for  at  least  several  months. 

Treatment. — ^To  eliminate  worms  from  the  body,  the  tsenicide  should 
be  given  for  several  days  and  then  followed  by  a  brisk  cathartic.  The  fol- 
lowing formulas  have  served  me  very  well : — 

R,  Magnesii  sulphatis   4  drachms 

Syrupi  rubi  idisi   2  fluid  ounces 

M.  Sig. :  A  tablespoonful  two  or  three  times  a  week,  to  be  preceded  by 
santonin/  spigelia,  or  chenopodium.    Once  a  day  a  high  enema  of  soapy  water  should 

^  The  formula  for  santonin  is  given  in  the  chapter  on  "Oxyuris  Vermicularis." 


292  DISEASES  OF  THE  INTESTINES. 

be  given.     The  folds  of  the  anus  should  be  carefully  cleansed  with  soap  and  water, 
and  the  following  ointment  applied: — 

B  Acidi    borici    1  drachm 

Olei  rosae 3  drops 

Vaseline 1  ounce 

M.     Sig. :     Apply  externally. 

Other  tenicides  recommended  by  Townsend  are: — 

I^  Ext.  spigeliae 10  fluid  ounces 

Ext.  sennse 6  fluid  ounces 

Olei  anisi 20  minims 

Olei  cari   20  minims 

M.  Sig.:  Half-teaspoonful  for  a  child  2  years  old,  two  or  three  times  daily. 
Teaspoonful  for  a  child  from  4  to  10  years  old. 

Or:— 

B  Oil  of  chenopodium  2  drachms 

Sig. :     To  be  given  on  sugar  three  times  daily,  in  doses  of  5  drops,  to  a  child  of 

3  years.     Ten  drops  to  a  child  of   10  years.     A  cathartic  should  be  given  every 

second  or  third  day. 

OxTUEis  Vermiculaeis  (Pinwoem;  Threadwoem). 

The  female  worm  is  thin,  yellowish  white,  and  has  a  pointed  tail. 
The  male  has  a  strongly  curved  tail.  The  male  worm  is  rarely  found  in 
the  stool.  The  female  worm  is  present  in  greater  number  than  the  male. 
The  oxyuris  is  frequently  passed  in  the  mucus  during  a  catarrhal  discharge 
from  the  rectum.  These  worms  frequently  wander  from  the  rectum  into 
the  vagina. 

Symptoms. — Irritation  and  itching  of  the  anus,  causing  restlessness 
and  severe  nervous  manifestations,  usually  appear  after  the  child  is  in  a 
warm  bed.  The  itching  frequently  gives  rise  to  a  desire  for  frequent 
urination.  In  severe  cases  it  may  lead  to  masturbation.  The  constant 
scratching  to  relieve  the  itching  has  produced  vulvitis  and  vaginitis.  Con- 
vulsions have  been  brought  on  by  reflex  irritation  due  to  the  presence 
of  worms. 

Treatment. — Threadworms  are  most  effectually  and  easily  removed 
by  the  use  of  enemata.  For  this  purpose  lime  water,  or  an  infusion  of 
quassia,  or  solution  of  common  salt  (a  teaspoonful  of  salt  to  4  ounces 
of  water)  may  be  employed.  In  using  these  agents  the  bowels  should  first 
be  cleansed  by  a  copious  injection  of  warm  water.  Jacobi  recommends  a 
decoction  of  garlic  as  an  enema  in  these  cases. 

IJ  Santonin    1  to  2  grains 

Mild  chloride  of  mercury  i^  grain 

M.  Sig.:  Every  night  for  two  or  tliree  nights,  to  a  child  5  or  6  years  old, 
and  followed  each  morning  by  a  purgative  dose  of  castor-oil. 


UNCINARIASIS.  293 

Or:— 

IJ  Santonin    1  grain 

Compound  liquorice  powder 2  drachms 

(Eustace  Smith.) 

Uncinariasis  (Hookworm  Disease). 

The  American  worm  was  discovered  in  1899  by  Dr.  Bailey  K.  Ashford. 
It  is  named  Necator  americanus.  It  is  about  half  an  inch  in  length,  and 
has  the  appearance  of  soiled  spool  cotton.  The  larva;  enter  the  system 
through  the  soles  of  the  feet,  and  finally  lodge  in  the  intestinal  tract. 

The  symptoms  are  extreme  pallor  of  the  skin,  profound  anaemia,  ex- 
cessive appetite,  occasional  abdominal  pains,  and  tenderness.  The  bowels 
may  be  constipated  or  loose;  the  stool  is  foetid.  There  is  palpitation  of  the 
heart — a  hasmic  murmur.  Haemoglobin  percentage  drops  to  between  30  and 
60  and  the  red  cells  from  3,500,000  to  4,000,000  per  cubic  centimeter. 
There  is  a  marked  eosinophilia.  There  is  marked  weakness  and  a  disin- 
clination to  play. 

When  the  symptoms  are  more  severe,  there  is  an  oedema  of  the  feet 
and  ankles,  and  pufliness  of  the  face  is  noted.  Sometimes  a  jaundiced 
condition  exists.  Some  cases  show  emaciation.  The  nervous  system  is  dis- 
turbed, there  is  marked  insomnia,  and  the  urine  contains  traces  of  albumin, 
but  no  casts. 

The  stools  should  be  examined  for  the  ova  while  fresh.  The  ova  are 
found  with  greater  ease  in  partially  formed  or  soft  stools.  In  preparing 
specimens  a  drop  of  water  is  placed  on  a  clean  slide  and  a  bit  of  faecal  matter 
is  taken,  up  on  a  platinum  loop;  this  is  thoroughly  mixed  and  a  cover  glass 
placed  over  the  specimen,  after  which  it  is  examined  with  a  ^/g  objective. 

Treatment  consists  in  giving  thymol  in  5-grain  doses,  every  hour  for 
4  doses.  In  view  of  the  toxic  qualities  of  thymol,  it  is  advisable  to  thor- 
oughly test  the  eucalyptus  treatment,  whicli  is  recommended  by  many  treat- 
ing this  disease. 

IJ  Eucalyptus  oil  2  drops 

Chloroform    1  drop 

Castor  oil 2  drachms 

Sig. :     One  dose  t.  i.  d.     Repeat  treatment  several  days. 

Chenopodium  oil  has  been  successfully  used  in  the  treatment  of  this 
disease.  It  should  be  given  in  5-  to  10-  minim  doses  on  a  lump  of  sugar, 
and  repeated  if  necessary  in  two-hour  intervals  until  three  doses  have  been 
taken.    After  the  last  dose  several  teaspoonfuls  of  castor  oil  should  be  given. 


CHAPTER  V. 

DISEASES  OF  THE  RECTUM. 

Fissure  of  the  Anus. 

An  ulcer  having  its  long  diameter  parallel  with  the  long  axis  of  the 
bowel  is  occasionally  met  with.  It  occurs  at  the  anal  margin.  It  is  seen 
in  infants  as  well  as  in  older  children.  It  is  caused  b}'  the  passage  of 
irritating  hard  fgecal  masses.  It  is  also  occasionally  seen  after  prolonged 
diarrhoea  with  continuous  straining.  Some  authors  state  that  traumatism 
from  the  nozzle  of  a  syringe  may  cause  a  fissure.  This  I  have  never  been 
able  to  verify.  Streaks  of  blood  of  a  bright  red  color  will  usually  be  seen 
in  the  stools  when  a  fissure  is  present. 

The  prognosis  is  good. 

Treatment. — This  should  be  mainly  hygienic,  and  consist  in  thorough 
cleansing  of  the  parts.  The  application  of  solid  nitrate  of  silver  will 
usually  effect  a  cure.  The  bowel  should  be  relieved  daily  by  the  injection 
of  sweet-oil  or  glycerine  to  soften  the  fseces.  Some  authors  advise  stretch- 
ing the  sphincter  of  the  anus  and  keeping  the  parts  at  rest. 

Simple  Catarrhal  Proctitis. 

The  rectum  is  rarely  inflamed  without  additional  portions  of  the 
bowel  being  involved.  When  the  same  exists,  local  causes  must  be  looked 
for;  for  example,  carelessness  while  irrigating  the  rectum.  Mistakes,  such 
as  corroding  or  caustic  drugs,  can  set  up  an  inflammation.  An  instance 
of  this  kind  occurred  in  my  practice  when  a  child  received  a  strong  injec- 
tion of  carbolic  acid,  causing  inflammation.  Infection  extending  from 
the  vagina  or  urethra,  such  as  gonorrhoea  or  diphtheria,  can  cause  this 
condition.  Syphilis  has  been  known  to  affect  the  rectum.  In  simple  ca- 
tarrh the  pathological  lesions  are  the  same  as  those  found  higher  up  in  the 
gut. 

The  symptoms  are  pain  Avhen  the  bowels  move.  The  stool  contains 
mucus,  which  may  be  distinctly,  separate.  When  folds  of  mucous  membrane 
protrude  they  are  very  angry  looking  and  show  a  deep  red  pigmentation. 
Children  old  enough  will  complain  of  intense  burning  and  itching. 

The  treatment  consists  in  using  bland  injections  such  as  oatmeal 
water  or  starch  water;  when  severe  tenesmus  exists,  bicarbonate  of  soda, 
a  teaspoonful  to  a  pint  of  water,  is  beneficial. 

(294) 


ISClllO-RKCTAL  AJJSC'KSS.  ot)- 


Croupous  Proctitis. 


This  is  the  form  usually  associated  with  diphtheria  of  the  genitals. 
Large  and  small  pieces  of  mucous  membrane  are  found  mixed  with  the 
stool.  Pathogenic  bacteria,  such  as  the  streptococci  and  staphylococci,  are 
found  in  tlic  dejecta. 

The  treatment  consists  in  using  bland  antiseptic  irrigations,  bichlo- 
ride of  mercury,  1  to  5000,  or  a  normal  saline  solution,  repeated  several 
times  a  day.  If  diphtheria  is  present,  antitoxin  should  be  given  (see 
chapter  on  "Antitoxin"). 

If  syphilis  is  present  the  usual  treatment  for  the  same  (see  chapter 
on  "Syphilis")   is  indicated. 

Ulcerative  Proctitis. 

Tuberculous  ulceration  of  the  rectum  has  been  reported  by  Steffen; 
also  by  Holt.  Syphilitic  ulcers  are  rare  in  children.  There  is  usually 
bleeding  and  tenesmus.  The  blood  is  of  a  bright  red  color.  The  diagnosis 
is  easily  made  l^y  examination  with  a  speculum  and  by  no  other  means. 

The  treatment  is  very  difficult.  First,  cleanse  the  rectum.  Apply, 
locally,  nitrate  of  silver  with  the  aid  of  a  speculum.  The  insufflation  of 
iodoform,  dermatol,  or  europhen  is  very  useful. 

Hemorrhoids. 

This  condition  is  occasionally  met  with  in  children.  It  usually  ac- 
companies chronic  constipation.  The  persistent  constipation  associated 
with  cretinism  occasionally  causes  this  condition. 

An  instance  of  this  kind  was  seen  by  me  in  a  child  about  2V2  years  old,  which 
was  referred  to  me  because  it  could  neither  walk  nor  talk.  It  had  been  operated 
for  congenital  adenoids  by  Dr.  W.  Freudenthal.  The  case  had  been  under  the  treat- 
ment of  Dr.  A.  Jacobi  for  one  year.  In  this  case  chronic  constipation  was  associated 
with  hsemorrhoids.  The  stool  was  so  hard  and  dry  that  blood  was  occasionally 
found  after  severe  tenesmus.  Tiiyroid  treatment  was  directed  against  the  cretinism, 
and  malt  extract  ordered  to  overcome  the  constipation. 

The  usual  treatment  consists  in  removing  the  cause  as  much  as  pos- 
sible as  above  described. 

I  have  never  met  with  a  case  under  12  years  of  age  that  required 
operation,  although  instances  of  this  kind  are  occasionally  described  Id 
surgical  literature. 

Isctito-rectal  Abscess. 

In  excoriated  conditions  around  the  anus,  following  continued  diar- 
rhoea, an  infection  frequently  results  from  scratching.  Pyogenic  bac- 
teria undoubtedly  enter  the  lymph  channels. 


296  DISEASES  OF  THE  RECTUM. 

A  case  of  this  kind  Avas  seen  by  me  in  the  family  of  Dr.  J.  Grosner,  of  New 
York  City.  An  infant  nursing  at  the  breast  had  dyspeptic  symptoms,  such  as  flatu- 
lence, and,  later,  intestinal  catarrh.  An  ischio-rectal  abscess  developed  later  on.  It 
was  benign  and  required  a  simple  incision  with  careful  attention  to  asepsis.  This 
condition  lasted  in  all  about  two  weeks.     The  child  made  a  splendid  recovery. 

At  times  we  meet  with  very  deep-seated  inflammation  which  requires 
the  skill  of  the  surgeon.  AVhen  a  fistula  exists  j^roper  surgical  treatment  is 
indicated. 

Prolapsus  Ani. 

When  children  strain,  especially  during  constipation,  prolapse  of  the 
anus  frequently  follows.  Not  infrequently  as  much  as  one  or  two  inches 
of  the  mucous  membrane  protrudes.     (See  Fig.  114.) 

Causes. — There  are  three  main  causes :  First,  weakness  of  the  levator 
ani  muscles.  In  general  atonic  conditions — for  example,  in  rickets — this 
condition  frequently  follows  constipation,  the  constipation  being  a  part 
of  the  rickety  condition  and  indirectly  causing  a  straining  during  defeca- 
tion, thus  ending  in  prolapse  of  the  rectum.  Deficient  peristalsis,  espe- 
cially in  young  children,  induces  them  to  strain  to  expel  hardened  faecal 
matter.  On  the  other  hand  constant  diarrhoea  and  irritation  in  the  lower 
bowel  may  also  result  in  prolapse.  When  an  attack  of  summer  complaint 
has  lasted  a  long  time,  Ave  usually  find  at  the  end  of  defecation  that  the 
rectum  protrudes. 

Second,  when  the  ischio-rectal  fat  is  deficient.  In  marasmic  condi- 
tions, such  as  in  athrepsia  infantum  or  following  the  acute  infectious  dis- 
eases, when  high  fever  and  general  wasting  have  taken  place,  the  body  fat 
suffers,  and  so  the  mechanical  support  of  the  rectum  is  lost. 

Third,  traumatic  condition.  This  condition  is  frequently  induced 
by  coughing  paroxysms,  hence  it  not  infrequently  follows  whooping-cough. 
Eetention  of  urine,  phimosis,  and  vesical  calculi  may  cause  this  condition. 

Diagnosis. — The  size  and  the  location  of  the  tumor,  and  its  appear- 
ance during  the  straining  while  at  stool,  render  the  diagnosis  easy.  The 
ease  with  which  the  prolapse  can  be  replaced  is  noteworthy  in  making  a 
.  diagnosis.  It  is  rare  for  this  condition  to  be  mistaken  for  intussusception 
(see  chapter  on  "Intussusception"). 

Treatment. — Local:  Place  the  child  in  the  knee-chest  position  and 
apply  olive-oil  to  the  prolapsed  bowel,  after  which  the  gut  can  be  replaced. 
When  this  mild  manner  of  reduction  is  not  successful,  a  whiff  of  chloro- 
form should  be  used  to  quiet  the  child.  This  will  also  relax  the  protruding 
part.  After  replacing  the  gut  the  buttocks  should  be  supported  by  a  stout 
strap  of  adhesive  plaster  running  from  side  to  side.  Cold  water  irrigations 
should,  be  given.     These  will  have  the  two-fold  object  of  emptying  the 


RECTAL  rOJAi'l.  397 

lower  bow.el  as  well  as  toning  the  muscle.  Astringent  injections  of  sulphate 
of  zinc,  1  grain  to  the  ounce,  or  tannic  acid,  10  grains  to  the  ounce,  are 
recoiniiiondcd  b}^  some.  1  liave  failed  to  see  any  benefit  therefrom.  The 
local  application  of  the  tincture  of  the  chloride  of  iron  once  every  three 
days  has  seemed  to  be  of  some  benefit.  The  solid  stick  of  riitrate  of  silver 
or  cauterization  by  means  of  the  Paquelin  cautery,  made  red  hot,  is  fre- 
quently recommended.  Heroic  measures,  such  as  amputation  of  the  parts, 
are  rarely,  if  ever,  necessary. 

Constitutional  Treatment. — We  must  not  expect  to  cure  a  condition 
of  this  kind  unless  the  body  is  strengthened.  IJestoratives,  cereals,  eggs, 
and  milk  must  be  prescribed.  We  can  supply  a  deficiency  of  fat  by  order- 
ing codlivor-oil  or  lipanin,  1  teaspoonful  three  times  a  day.  When  con- 
stipation exists  the  addition  of  malt,  as  in  a  malted  food,  will  aid  this 
condition.  Strychnine  may  be  given  in  doses  of  Yjoq  of  a  grain,  and 
increased  gradually  until  Voo  ^^  ^  grain  is  given,  three  times  a  day.  Iron 
can  also  be  given  with  great  advantage.  Massage  of  the  abdomen  and 
electricity  must  not  be  forgotten.  A  cold  shower  or  spray  over  the  spine 
and  abdomen,  repeated  every  day,  is  an  excellent  tonic. 


Rectal  Polypi. 

Polypus  of  the  rectum  is  very  common  in  early  life.  When  bleeding 
occurs  it  may  be  due  to  a  fissure  or  to  a  hard  scybalous  stool  tearing 
the  mucous  membrane.  It  may  be  caused  by  a  rectal  polypus.  Frequently 
we  find  this  condition  in  syphilis. 

The  treatment  consists  in  tying  off  the  polypus  with  fine  catgut  or 
snipping  the  polypus  with  a  scissors  and  then  cauterizing  the  base. 


CHAPTER  VI. 

DEFICIENCY  DISEASES  AND  DISORDERS  ARISING  FROM  THE  IMPROPER 

ASSIMILATION    OF   NUTRITION    WHEREBY    FAULTY 

METABOLISM    RESULTS. 

Faulty  Metabolism. 

This  condition  is  primarily  due  to  faulty  feeding,  or  to  conditions  asso- 
ciated with  improper  nutrition  whereby  faulty  metabolism  results.  It  is 
found  in  infancy,  but  is  also  very  prevalent  in  older  children  between  the 
ages  of  4  and  14  years.  We  find  a  subnormal  condition  of  the  skin  which 
may  be  cold  or  moist,  or  the  skin  may  be  found  dry,  and  the  circulation 
poor.  The  extremities  are  cold;  cyanosis  is  not  present.  Such  children 
frequently  have  marked  vasomotor  disturbances  manifested  by  unilateral 
flushes  of  the  face,  of 'one  ear,  or  the  nose.  The  elasticity  of  the  skin  is 
much  less  than  normal.  Adipose  tissue  is  usually  lacking,  although  this 
type  of  case  may  be  unusually  fat.  Such  adiposity  is  due  to  faulty  assimila- 
tion. The  child  shows  the  evidence  of  defective  nutrition.  It  is  underfed. 
If  it  is  not  underfed,  then  the  food  is  not  assimilated.  Sometimes  both 
quantity  and  quality  of  food  are  properly  regulated  and  still  subnormal 
conditions  prevail.  An  absence  of  the  internal  secretions  due  to  functional 
inactivity  of  various  glands  associated  with  the  digestive  tract  is  most 
pi'obable  because  such  cases  have,  first, 

Lienteric  stools  in  which  undigested  particles  of  food  may  be  found. 
Such  lienteric  condition  may  be  modified  by  a  stimulation  of  glandular 
activity,  such  as  the  salivary  and  peptic  glands.  We  must  not  undervalue 
the  role  played  by  the  pancreatic  ferments,  and  the  necessity  for  that  most 
important  of  all  glands,  namely,  the  liver.  Inactivity  on  the  part  of  the 
liver  and  the  absence  of  a  proper  secretion  of  bile  are  two  of  the  most 
potent  factors  in  causing  faulty  metabolism. 

Second.  Scybalous  Stools. — When  dry,  round,  fspcal  masses  stagnate  in 
the  colon  they  set  up  a  series  of  symptoms  which  yield  one  of  the  most 
frequent  sources  of  trouble  in  children.  In  this  type  of  stagnation  of 
fffices,  one  of  the  prime  causes  is  the  absence  of  tone  to  the  intestinal 
muscles,  but  the  dryness  and  lack  of  secretion  per  se  is  due  to  the  absence 
of  proper  lubrication  from  a  subnormal  mucous  membrane.  It  is  plain, 
therefore,  that  we  must  seek  the  origin  of  this  trouble  in  a  deficiency  of  the 
secretions  previously  named  or  in  the  absence  of  a  proper  secretion  of  bile. 
The  bile  salts,  especially  in  infancy  and  childhood,  have  a  most  important 
bearing  on  the  efficiency  of  digestion.  ITnless  the  liver  performs  its  func- 
tion, faulty  metabolism  is  inevitable.  Whenever  possible  the  urine  should  be 
examined  for  the  presence  of  indican.     Indicanuria  usually  accompanies 

(298) 


FAUJ/IY  METAUOLISM.  29!j. 

stagnation  of  intesiiiiiil  contents,  and  is  frequently  associated  with  symptoms 
that  make  up  a  clinieal  picture  of  autointoxication  of  the  intestine.  Fever, 
so-called  absorption  fever,  is  usually  a  bi-product  of  this  stagnation,  and  the 
temperature  will  range  from  100°  to  103°  F.  for  many  weeks,  or  until  the 
diet  is  so  reduced  and  the  gastrointestinal  tract  so  cleansed  that  intestinal 
stagnation  is  impossible. 

It  is  readily  seen  from  what  has  just  been  said  that  faulty  metabolism 
robs  the  bones  of  their  proper  nutrition,  and  by  a  deficient  quantity  of  blood 
the  nutrition  is  subnormal ;  hence  rickets  due  to  soft  bones  results.  A  defi- 
ciency of  lime  salts  in  the  bones  is  evident  in  the  teeth,  which  show  carious 
manifestations  and  a  breaking  down,  so-called  chalky  teeth. 

What  applies  to  the  bones  is  true  also  concerning  the  muscles.  The 
muscles  are  flabby  and  soft,  and  show  the  lack  of  tone  that  good  healthy 
muscular  tissue  should  show.  Such  children  are  ver}^  restless  at  night;  as  a 
rule  the  general  atony  of  the  muscles  of  the  bladder  results  in  enuresis. 

The  atony  of  the  intestine  is  evident  in  deficient  peristalsis  and  con- 
t-equent  coprostasis.  The  obstipation  if  present  results  from  dryness  and 
lack  of  secretion  in  the  intestine;  hence  scybalous  stools  are  noted. 

Faulty  metabolism  is  very  evident  in  the  nasopharyngeal  tract.  Such 
children  have  the  adenoid  liabitus,  they  are  prone  to  infections,  and  are 
constant  sufferers  from  tonsillitis  and  swelling  of  the  adenoid  vegetations. 
The  cervical  glands  are  usually  enlarged.  These  children  are  frequently 
victims  of  bronchitis  and  pneumonia. 

Owing  to  tliis  subnormal  condition  the  immunity  of  the  body  and  the 
phagocytosis  are  so  greatly  minimized  that  such  children  not  only  invite  all 
exanthematous  infections  but  frequently  succumb  therefrom.  Due  to  this 
lack  of  vitality,  one  is  not  surprised  to  see  a  slight  rhinitis  extend  through 
the  Eustachian  tube  and  set  up  an  otitis  media  ending  in  mastoid  infection. 
It  is  this  class  of  cases  which  if  first  seen  by  tlie  laryngologist  will  be 
treated  by  curetting  adenoids  if  present,  and  likewise  by  the  removal  of 
tonsils  if  hypertrophicd. 

Catarrhal  Tendencies. — These  cases  are  brought  to  the  pediatrist  weeks 
and  months  after  such  primary  operation  for  the  relief  of  three  serious 
symptoms  which  were  the  reason  for  the  nasopharyngeal  treatment.  These 
symptoms  are :  loss  of  appetite,  no  gain  in  weight,  and  general  restlessness 
and  irritability.  These  three  symptoms  stand  out  prominently  in  the  picture 
which,  summed  together,  spells  faulty  metabolism. 

Nervous  Manifestations. — There  is  an  irritability  and  sensitiveness 
simulating  hysteria  in  the  adult.  Such  children  are  easily  dissatisfied. 
They  cry  on  the  slightest  provocation.  They  are  peevish  and  hard  to  please. 
This  applies  not  only  to  their  clothing,  surroundings  and  playmates,  but, 
equally  so,  their  food  cravings  are  al)normal.  They  insist  on  sweets,  also 
crave  sour  foods  and  condiments.     Biting  of  the  nails,  thumb  sucking  and 


300  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

masturbation  in  the  form  of  thigh  friction  may  be  started  by  an  excoriation 
around  the  genitals  and  anus,  caused  by  very  acid  or  ammoniacal  urine. 

I  have  been  requested  to  examine  such  cases  for  a  suspicion  of  tuber- 
culosis. The  picture  does  resemble  tuberculosis,  although  no  tubercle  bacilli 
exist  in  the  expectoration.  Such  children  will  not  give  a  cutaneous  reaction 
when  scarrified  with  tuberculin.  The  physical  signs  in  the  chest  are 
negative,  although  rhonchi  may  occasionally  be  heard. 

These  cases  frequently  have  a  distinct  resemblance  to  hereditary 
syphilis.  The  diiferential  diagnosis  can  be  determined  by  securing  an 
honest  family  history,  and  noting  the  presence  or  absence  of  Hutchinson's 
teeth.  If  still  in  doubt  with  the  absence  of  such  important  data,  a  Wasser- 
niann  reaction  will  aid  in  establishing  the  diagnosis.  Faulty  metabolism  is 
an  important  factor  in  tuberculosis  as  well  as  syphilis,  and  the  exclusion  of 
such  diseases  must  be  positive.  There  are  thousands  of  children  whose 
sallow  appearance  and  shriveled  skin  imply  an  abnormal  state  of  health 
which  requires  vigorous  treatment  if  results  are  to  be  obtained. 

Treatment. — If  we  are  dealing  with  a  distended  colon  or  distention  of 
the  stomach  associated  with  flatulence  or  eructations  of  gas,  then  starches 
in  all  forms  must  be  excluded.  Potatoes,  bread,  cake,  and  all  flour  foods 
must  be  stopped.  In  addition  thereto  all  cereals  such  as  rice,  barley,  and 
cornstarch  must  be  excluded.  The  stool  should  be  examined  to  see  whether 
it  contains  gaseous  bubbles  and  mucus  or  whether  the  consistency  is  solid. 
In  a  young  child  a  strict  diet  of  milk,  eggs,  and  cream  cheese  is  indicated. 
An  older  child,  besides  milk,  cheese,  and  eggs,  may  have  junket,  custard,  fish, 
meat,  and  all  green  vegetables.  Stewed  fruits  and  fresh  fruits  are  indicated. 
The  question  of  assimilation  of  food  depends  greatly  on  a  regular  four  or 
five  hour  interval  between  each  meal,  with  fresh  air  and  out-door  exercise, 
and  not  overfilling  or  overtaxing  the  stomach  with  large  meals. 

Nux  vomica  in  doses  of  1  to  5  drops  before  each  meal,  depending  on 
the  age  of  the  child,  is  an  excellent  tonic.  Pancreatin  ifi.  doses  of  1  or  2 
grains  may  be  combined  with  the  nux  vomica. 

The  weight  is  an  important  guide  as  to  the  progress  of  proper  metabo- 
lism. A  mild  laxative  such  as  15  to  20  grains  of  calcined  magnesia  can  be 
given  every  morning  if  necessary.  The  child  must  not  be  permitted  to 
retire  without  an"  evacuation  of  the  bowel.  One-half  pint  of  soap-water 
may  be  given  as  an  enema  if  necessary. 

A  change  of  air  from  the  city  to  the  seashore  for  several  months  during 
winter  or  summer  will  frequently  aid  in  establishing  normal  conditions. 
Some  children  will  be  benefited  by  a  change  to  the  mountains.  The  influ- 
ence of  a  tepid  bath  followed  by  a  cool  shower,  or  a  cold  bath  in  the  morning, 
if  the  child  can  tolerate  the  same,  is  an  excellent  tonic.  Such  cool  baths 
should  be  followed  by  friction  of  the  skin  to  stimulate  the  cutaneous  circula- 
tion..   It  is  an  excellent  vasomotor  stimulant. 


SCURVY.  301 

Some  of  these  cases  may  require  a  mild  I'aradic  current  of  electricity 
applied  over  the  stomach  and  intestines.  By  such  treatment  the  plexus  of 
nerves  is  easily  stimulated  to  advantage.  The  electricity  should  be  given 
for  several  minutes  every  other  day,  and  if  well  tolerated  may  be  given  daily 
for  a  month  or  more. 

Scurvy  (Scorbutus:  Barlow's  Disease). 

This  is  a  constitutional  disease  resulting  from  improper  feeding. 

Etiology. — It  usually  occurs  before  the  end  of  the  second  year,  and 
rarely  occurs  before  the  first  six  months  of  a  child's  life.  As  in  adults, 
scurvy  is  found  when  fresh  food  has  been  withdra\\Ti  from  the  dietary.  It 
is  natural,  therefore,  to  look  for  scorbutic  cases  among  children  who  are : — 

First,  deprived  of  breast-milk. 

Second,  in  those  brought  up  exclusively  on  milk  which  is  devitalized  by 
prolonged  sterilization. 

Third,  it  is  found  in  children  brought  up  on  condensed  milk  and  on 
those  proprietary  foods  to  which  fresh  milk  has  not  been  added.  There 
seems  to  be,  tlierefore,  a  direct  relationship  between  the  absence  of  fresh 
milk,  be  it  cows'  milk  or  human  milk,  and  the  development  of  this  disease. 
It  is  a  great  mistake  to  attach  importance  to  the  fact  that  an  infant  was 
fed  on  a  proprietary  food  unless  we  know  whether  or  no  fresh  milk  was 
added.  It  is  the  absence  of  the  live  factor  in  fresh  milk  Avhich  directly 
causes  scurvy. 

Troup,  of  Christiana,  quoted  by  Koettlitz,^  is  strongly  of  the  opinion 
that  scurvy  is  the  result  of  a  scorbutic  element  of  the  nature  of  a  ptomaine 
present  in  the  diet.  Jackson  and  Yaughan  Harley,^  as  a  result  of  an 
experimental  inquiry  into  scurvy,  arrived  at  much  the  same  conclusion. 
The  question  under  discussion  here  is  whether  or  not  infantile  scurvy  is 
the  result  of  the  absence  of  some  essential  element  in  the  diet  or  the  pres- 
ence of  some  scorbutic  factor.  It  is  certain  that  an  infant  fed  for  a  long 
period  upon  peptonized  milk^  will  develop  scurvy,  but  if  potato  gruel  and 
raw  meat  juice  are  added,  yet  no  otirer  alteration  made  in  the  diet  and  no 
medicine  given,  the  scurvy  will  rapidly  disappear  and  the  child  be  well 
in  a  few  weeks.  Thus  the  addition  of  a  fresh  element  to  the  scurvy  diet 
has  cured  the  condition.  Moreover,  many  of  the  diets,  for  example,  oat- 
meal and  water,  upon  which  the  young  children  become  scorbutic,  seem 
to  exclude  the  possibilities  of  the  development  of  ptomaines.  The  experi- 
ments of  Jackson  and  Harley  do  not  carry  conviction  that  true  scurvy 
has  been  produced  in  animals,  but  rather  that  a  condition  of  ptomaine 
poisoning  has  resulted.     It  is  possible  that  unsound  food  may  hasten  the 

■■Guy's  Hosp.  Gazette,  March  30,   IflOl. 
-Proceedings  Royal  Society,  March,  1900. 

'The  prolonged  use  of  peptogenic  milk  powder  will  produce  scorbutic 
manifestivtious. 


302  DISORDERS  RESULTING  PROM  IMPROPER  NUTRITION. 

development  of  scurvy,  but  the  evidence  at  present  seems  insufficient  to 
invalidate  the  conclusion  that  infantile  scui-vy  is  due  to  the  absence  of 
an  anti-scorbutic  element  rather  than  to  the  presence  of  some  scorbutic 
poison. 

■Summary  of  Essential  Conditions. — The  six  essential  conditions  to  be 
observed  in  the  diet  of  infants  are  these : — 

1.  The  food  must  contain  the  different  elements  in  the  proportions 
which  obtain  in  human  milk,  viz. : — - 

Protein     1.5  per  cent. 

Fat    3.5  per  cent. 

Carbohydrate    6.5  per  cent. 

Salts     0.2  per  cent. 

Other    constituents    0.6  per  cent. 

Water     87.7  per  cent. 

100.0 

2.  It  must  possess  the  anti-scorbutic  element. 

3.  The  total  quantity  in  twenty-four  hours  must  be  such  as  to  rep- 
resent the  nutritive  value  of  1  to  3  pints  of  human  milk,  according  to 
age,  viz. : — 

Protein     225  to       675  grains 

Fat    231   to        693  grains 

Carbohydrates     613  to     1839  grains 

4.  It  must  not  be  purely  vegetable,  but  must  contain  a  large  propor- 
tion of  animal  matter. 

5.  It  must  be  in  a  form  suited  to  the  physiological  condition  of  the 
digestive  function  in  infancy. 

6.  It  must  be  fresh  and  sound,  free  from  all  taint  of  sourness  or 
decomposition. 

Pathology. — Haemorrhages  in  and  around  the  joints  and  in  the  mus- 
cles are  found  post-mortem.  The  most  important  point,  however,  is  the 
presence  of  subperiostial  hgemorrhage  involving  the  long  bones.  Eotch 
states  that  the  femora  are  the  most  commonly  affected,  and  that  there  is 
a  tendency  to  a  separation  of  the  epiphyses.  Interstitial  haemorrhage  in- 
volving the  lungs,  spleen,  kidneys,  and  interstitial  glands  has  been  found. 
When  the  kidneys  are  involved  we  can  usually  find  hfematuria.  Hsemor- 
rhages  are  frequently  present  in  the  mucous  surfaces;  thtis  the  gums  show 
a  deep  purple  color,  besides  being  swollen  and  presenting  the  character- 
istic spongy  appearance. 

We  are  indebted  to  Barlow  for  his  valuable  studies  regarding  the 
pathology  and  symptomatology  of  this  disease.  The  blood  shows  no  specific 
changes  which  are  pathognomonic  to  this  disease. 


PLATE  XI 


Infantile  Scniny.^  Ellen  S.  Five  years  old.  The  gnms  are  swollen 
01"  beefy  and  hnnging  in  tuniov-like  masses.  There  are  also  blood-tumors  on 
the  forehead.  (From  the  pathological  laboratory  of  the  Great  (^rniond  Street 
Hospital,  London.     Conrtesy  of  Sir  Thomas  Barlow.) 

'I  am  indebted  to  Dr.  Richard  Armstrong,  of  the  Great  Ormond  Street  Hospital, 
London,  for  valuable  assistance  in  procuring  Plates  XIV  and  XV. 


PLATE  XII 


Infantile  Scurvy.  Femur  divided  by  anteroposterior  section,  showing 
the  cliaracteristic  scorbutic  changes ;  including  fracture  of  the  shaft  at  about 
a  quarter  its  length  from  the  head,  and  displacement  of  the  upper  epiphysis. 
The  especial  feature  is  the  wide  separation  of  the  periosteum  from  the  upper 
half  of  the  bone  by  new  bone  which  has  been  organized  from  a  pre-existing 
subperiosteal  hiiemorrhage. 


SCURVY.  303 

Bacteriology. — No  specific  Ijucterium  lias  as  yet  been  found  nor  d(je.s 
the  blood  show  any  peculiarities  l)acteriologically. 

Symptoms  and  Diagnosis. — The  symptoms  are  marked  irritability  by 
day  and  I'csth'ssness  at  night,  associated  with  insomnia.  The  mother  or 
nurse  will  usually  say  that  the  child  cannot  be  satisfied  and  cries  when- 
ever touched,  most  especially  when  the  arms  and  legs  are  moved.  It  is 
very  apparent  that  there  is  pain  due^  to  a  swelling  of  the  limbs,  usually 
of  the  diapliyses  just  above  the  epiphyses.  When  not  disturlx^d  these 
children  seem  to  lie  quietly.  Swelling  of  the  limbs  in  the  legs  and  fore- 
arm is  usually  present.  While  the  skin  over  the  swelling  is  tense  there  is 
no  evidence  of  fluctuation.  Tenderness  on  pressure  is  usually  noted. 
Bluish-black  spots,  due  to  small  subcutaneous  haemorrhages,  are  visible. 
When  hannorrhages  affect  the  deeper  parts  around  the  eyes  so  that  the  eye 
itself  will  be  pushed  forward,  a  condition  called  proptosis  will  be  noted. 
This  condition  of  proptosis  is  found  in  advanced  cases  of  scurvy. 

Owing  to  pain  in  the  limbs  the  child  does  not  appear  to  move,  giving 
rise  to  the  impression  that  the  child  is  paralyzed.  When  this  condition 
is  seen  in  scurvy  it  has  been  called  pseudo-paralysis.  The  gums  are  very 
spongy  and  swollen,  and  have  bluish  maculae  over  the  surfaces.  The  child 
shows  the  evidences  of  marked  anagmia  and  loss  of  weight.  There  is  loss 
of  appetite,  and  when  food  is  taken  the  head  perspires  freely.  The  tem- 
perature rises  in  the  evening  to  between  100°  and  101°  F.  The  pulse  is 
small,  feeble,  and  ranges  between  120  and  140.  The  respirations  are  not 
affected.  The  clinical  picture  is  one  of  marked  malnutrition  with  symp- 
toms simulating  tuberculosis. 

This  disease  is  liable  to  occur  in  either  sex;  it  is  not  influenced  b}'' 
climate  or  locality ;  it  is  found  as  well  in  the  best  as  in  the  poorest  hygienic 
surroundings.  By  far  the  greatest  number  of  cases  is  found  among  the 
rich.  It  is  evident  that  this  disease  is  due  to  improper  feeding  more  than 
to  an  improper  h^'-giene.  Some  authors  believe  that  this  disease  is  caused 
by  a  specific  micro-organism;  this  latter  fact  has  not  yet  been  definitely 
settled. 

It  is  interesting  to  note  the  various  views  expressed  by  competent 
observers  upon  this  subject;  thus,  while  a  large  majority  of  clinicians 
hold  that  sterilized  milk  per  se  does  cause  scurvy,  Eotch  states  that  it  does 
not,  in  his  own  experience,  seem  to  do  so.  Starr  maintains  just  the  reverse 
and  believes  that  sterilized  milk  is  a  causative  factor.  From  my  own  ex- 
perience I  quite  agree  that  sterilized  milk — especially  the  prolonged  ster- 
ilization, by-which  the  albumins  are  changed,  and  by  which  this  prolonged 
heating  causes  devitalization,  which  is  so  inimical  to  successful  feeding — is 
a  causative  factor  in  this  disease. 

It  is  peculiar  that  scurvy  will  be  cured  by  giving  raw  milk,  fr-osh 
fruits,   and   acid   fruits;   still   we   find  that   a   great   many   clinicians   per- 


304  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

sist  in  prescribing  sterilized  milk  until  either  rickets  or  scurvy  is  estab- 
lished. It  was  for  this  reason  Hhat  at  a  discussion  on  infant  feeding  at 
the  Academy  of  Medicine,  October  18,  1900,  I  was  led  to  insist  on  the  use 
of  raw  milh  as  the  proper  means  of  feeding  children. 

Eaw  milk  possesses  certain  advantages  over  boiled  milk;  it  is  more 
readily  assimilated,  and  the  proteins  are  not  so  difficult  to  digest.  It  is  a 
well-knovm  fact  that  boiled  milk  and  sterilized  milk  have  a  tendency  to 
produce  constipation,  whereas  the  opposite  is  true  of  raw  milk. 

Improper  infant  food  has  additional  disadvantages  when  it  is  sub- 
jected to  excessive  heating.  The  large  number  of  failures  with  milk  modi- 
fied at  a  laboratory  are  not  so  much  due  to  the  process  involved  in  the 
modification  as  to  the  amount  of  heat  that  the  food  is  subjected  to  prior 
to  being  imbibed. 

Where  milk  is  modified  for  infant  feeding,  using  raw  milh  only,  I 
have  seldom  seen  constipation ;  the  reverse,  however,  has  always  been  true 
when  milk  was  modified  and  then  subjected  to  sterilization.  The  vital 
point  has  always  impressed  me  as  being,  not  so  much  to  sterilize  milk  after 
it  has  been  drawn  from  the  cow,  but  to  apply  the  principle  of  sterilization 
to  the  stable,  the  cow,  the  utensils,  the  milker's  hands,  and  to  everything 
-corning  into  contact  with  the  milk  from  the  time  it  leaves  the  cow's  udder 
until  it  is  fed  to  the  baby. 

When  oatmeal  gruel  or  barley  gruel  is  given  with  an  insufficient  quan- 
tity of  cows'  milk  and  then  fed  for  a  long  time,  we  must  not  he  surprised 
ip  find  a  case  of  scurvy.  When  proprietary  foods  are  given  without  the 
addition  of  fresh  milh,  then  scurvy  will  usually  result.  When  cream 
mixtures  are  given  which  are  deficient  in  fat  and  proteins,  then  scurvy 
may  result.  Thus  we  find  that  the  true,  underlying  cause  of  scurvy  is 
starvation  due  to  deficiency  of  one  or  more  nutritive  elements  in  the  food 
given. 

The  following  cases  of  scurvy  will  illustrate  the  condition : — 

Case  I. — Joe  W.,  thirteen  months  old,  was  seen  by  me,  in  consultation  with 
Dr.  Samuel  Barbash,  at  Atlantic  City,  October,  1912.^  The  infant  was  bottle  fed 
from  birth.  He  was  given  condensed  milk  the  first  month  and  later,  for  a  period  of 
seven  months,  received  Borden's  malted  milk.  He  was  then  put  on  cows'  milk,  which 
disagreed.  The  infant  had  mucous  stools,  which  were  streaked  with  blood.  His 
general  development  was  fair,  although  a  bronzed  condition  of  the  skin  existed.  He 
had  the  first  tooth  when  four  months  old,  and  was  able  to  stand  on  his  feet  several 
weeks,  until  four  weeks  ago.  It  was  then  noted  that  he  suddenly  refused  to  stand, 
and  that  the  slightest  handling  of  the  joints  of  his  arms  and  legs  produced  severe 
pains.    A  diagnosis  of  articular  rheumatism  was  made. 

There  was  marked  tenderness  over  the  joints.  The  head  perspired  freely  when 
food  was  taken.  The  gums  were  soft  and  tender,  and  had  a  bluish-red  ridge  around 
the  teeth.     The  weight  at  the  age  of  thirteen  months  was  12%  pounds,  which  in 

"^  Case  presented  at  the  meeting  of  the  Atlantic  County  Medical  Society,  October 
11,  1912. 


PLATK  XIII 


Scurv\'.     Subperiosteal  Haemorrhages.     Infant  nine  months  old. 
(Courtesy  of  Dr.  A.  George.) 


SCURVY.  305 

itself  is  sufficient  to  show  faulty  metabolism.  There  was  a  marked  rachitic  rosary, 
and  beaded  ribs  on  both  sides,  so  that  the  diagnosis  of  scurvy  and  rickets  was 
warranted. 

The  sudden  onset  of  symptoms  made  the  case  resemble  a  form  of  infantile 
paralysis.  When  the  symptoms  are  associated  with  the  bleeding  gums,  the  purplish, 
spongy  swellings,  and  the  bluish-black,  subcutaneous  hjEmorrhagcs  visible  on  the 
inside  of  the  cheek,  then  the  diagnosis  of  pseudo-paralysis  associated  with  scorbutus 
must  be  made. 

Case  II. — A  child  thirteen  months  old  was  brought  to  me  with  a  history  of  being 
very  restless  and  having  lost  considerable  weight.  The  child  showed  a  shriveled  ap- 
pearance of  the  skin;  its  normal  elasticity  was  gone;  the  skin  was  dry;  the  thorax 
was  pigeon-breasted;  the  arms  and  legs  were  thin;  both  arms  and  legs  showed  marked 
tenderness  on  the  slightest  motion;  there  was  baldness  at  the  occiput,  and  the 
anterior  fontanel  was  not  closed;  the  child  had  eight  teeth,  all  of  which  were  slightly 
carious;  the  gums  around  the  teeth  were  deeply  congested  and  showed  bluish  ridges; 
the  gums  were  spongy  and  bled  very  easily;  there  was  an  intense  foetor  to  the 
breath;  the  child  had  been  suflfering  from  diarrhoea  for  the  past  two  months,  with 
occasional  periods  of  constipation;  there  was  no  vomiting;  the  appetite  had  always 
been  very  poor.  The  previous  history  of  the  child  was  that,  when  born,  it  weighed 
about  5  pounds;  it  was  very  small  at  birth.  The  mother  of  the  child  died  during 
confinement,  and  hence  the  baby  was  given  into  the  care  of  a  nursery.  The  diet 
consisted  of  1  teaspoonful  of  condensed  milk  with  12  teaspoonfuls  of  water  and  a 
small  pinch  of  sugar.  This  was  fed  every  two  hours  for  a  period  of  over  two  montlis ; 
later  the  child  was  put  on  barley  water,  to  which  some  condensed  milk  was  added. 
This  was  changed  from  time  to  time  to  a  diet  of  oatmeal  water  and  condensed  milk. 

The  child  had  always  been  frail,  and  had  a  cough  and  also  an  attack 
of  acute  capillary  bronchitis;  during  the  summer  the  child  had  a  severe  attack  of 
cholera  infantum,  and  almost  lost  its  life  from  vomiting  and  purging.  For  one 
month  this  child  subsided  on  a  diet  of  oatmeal  water,  rice  water,  farina  water,  and 
albumin  water,  besides  cold  tea.  Thus  it  is  seen  that  the  child  received  no  milk  for 
a  period  of  over  seven  weeks.  When  the  child  was  five  months  old  it  weighed  7 
pounds,  and  at  this  time  it  hardly  weighs  10  pounds.  There  is  a  marked  rachitic 
kyphosis;  the  ribs  are  beaded;  there  is  a  pendulous  belly;  the  child  has  an  umbilical 
hernia;  the  temperature,  taken  in  the  rectum  at  2  p.m.  for  a  period  of  at  least 
two  weeks,  was  no  higher  than  100°  to  101°  F. ;  there  is  an  intense  thirst;  the 
kidneys  are  very  active;  the  urine  has  a  very  high  color;  no  haematuria  could  be 
found. 

The  diagnosis  of  infantile  scurvy  was  made,  and  the  child  was  put  on  the 
following  treatment:  Orange  juice;  lemonade;  freshly  expressed  steak  juice;  raw 
milk,  diluted  with  barley  water  or  rice  water,  equal  parts  (4  ounces  of  milk,  4  ounces 
of  barley  water),  repeated  every  three  or  four  hours,  depending  upon  the  appetite. 
Massage  of  the  body  was  very  gently  performed  with  codliver-oil  or  vaseline,  to 
lubricate  and  to  nourish.  A  1-drop  dose  of  nux  vomica  was  ordered  before  each 
feeding.  This  treatment  was  given  continually  for  three  or  four  weeks.  Every 
fourth  or  fifth  day  a  half-ounce  of  barley  water  or  rice  water  was  withdrawn,  and 
instead  an  equal  quantity  of  fresh  milk  was  added;  hence,  after  four  weeks  of 
treatment  this  child  received  6  ounces  of  milk  with  2  ounces  of  barley  water  or  rice 
water  every  four  hours. 

The  child  was  sent  to  the  seashore,  and  after  this  treatment  was  continued  for 
seven  months  all  symptoms  of  scurvy  had  disappeared;  the  child  recovered. 

20 


308 


DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 


The  increased  proliferation  of  cells  makes  the  epiphysis  larger,  swollen 
in  appearance,  irregular  in  outline,  and  much  softer  in  consistence.  It  has 
been  experimentally  proven  that  hypersemia  of  bone  causes  defective  de- 
compositions of  lime  salts.  Owing  to  this  deficiency  of  lime  salts  the  bones 
become  very  soft  and  flexible.  While  normally  there  is  two-thirds  mineral 
matter  in  the  bones,  in  rickets  this  is  reduced  to  one-third.  Thus  we  can 
easily  explain  the  various  "rachitic  deformities'^  which  are  especially  noted 


Fig._84 


Fig.  85 


Cranial,  Thoracic,  and  Abdominal  Type  of  Rickets. 

Fig.  84. — Hydrencephaloid  ( Spurious  Hydrocephalus ) .  Infant  8 
months  old.  Bottle-fed.  Suffering  with  cholera  infantum.  Severe  nervous 
and  toxic  symptoms. 

Fig.  85. — Same  Child  Two  Years  Later.  Note  the  square  head,  the 
frontal  protuberance.  Also  the  Harrison  groove  and  the  pendulous  belly. 
(Original.) 

in  the  femur,  the  tibia,  the  radius,  the  ulna,  and  the  ribs.  When  ossifica- 
tion is  retarded  during  rickets,  as,  for  example,  in  the  parieto-occipital 
region,  the  bone  is  frequently  so  thin  that  it  yields  to  pressure;  this  is 
called  craniotabes. 

The  fontanels  are  not  closed  until  very  late,  owing  to  this  delayed 
ossification.  The  frontal  and  parietal  protuberances  are  very  much  en- 
larged, due  to  exaggerated  proliferation  of  the  periosteum,  so  that  the 


M 


P. 


VLATK  XV 


Rickets.     Note  the  flaring,  cup-shaped,  irregular  termination  of  the  diapliysis. 
Condition  accounts  for  the  enlargement  of  ankles  in  rickets. 


RACHITIS.  309 


ft -^***/         *  i'. « 


'fyW"W<^mjL^2Mi-  ■  m 


Fig.  86. — Rickets.  Longitudinal  section  through  the  ossification  junc- 
tion of  the  upper  diaphyseal  end  of  the  femur  of  a  one-year-old  child  suffer- 
ing from  rachitis  of  moderate  degree,  a,  Unaltered  hyaline  cartilage.  6, 
Cartilage  in  the  first  stage  of  proliferation,  c,  Zone  of  proliferated  cartil- 
age cell  columns,  d,  Columns  of  proliferated  hypertrophic  cells,  e,  vessels 
located  in  the  cartilage,  with  fihrous  marrow  tissue,  f.  Decalcified  cartilage 
tissue,  g.  Osteoid  tissue,  h.  Remains  of  cartilage  tissue  in  osteoid  tissue, 
i,  Trabeculae  of  decalcified  osteoid  tissue,  k,  Trabeculae  of  osteoid  and  fully 
formed  calcified  bone  tissue.     I,  Fibro-cellular  marrow  tissue.      (Ziegler.) 


310  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

head  acquires  a  broad  forehead  with  characteristic  frontal  prominerce. 
This  condition  is  frequently  taken  for  hydrocephalus.  When  ossification 
takes  place  the  bones  become  large,  heavy,  and  irregular  in  outline,  corre- 
sponding to  the  clinical  manifestations  known  as  "bow-legs,"  "knock-knees," 
"pigeon-breast,"  "spinal  curvature,"  and  "square  cranium." 

Where  the  bone  joins  the  cartilage,  as,  for  example,  on  the  ribs,  en- 
largements occur  which  simulate  beads ;  hence  the  term  'Treaded  ribs,"  also 
called  "rachitic  rosary."  The  same  enlargements  can  be  felt  at  the  wrists, 
ankles,  and  knees. 

A  section  through  the  epiphyseal  Junction  of  a  rachitic  bone  shows  a 
very  vascular,  bluish-colored  condition,  which  is  softer  than  normal  when 


Fig.  87. — Spurious  Hydrocephalus,  Ilkistrating  Marked  Frontal  and 
Parietal  Protuberances.  There  was  a  striking  resemblance  to  a  case  of 
hydrocephalus.     Bottle-fed.     Rachitic.     (Original.) 

cut.  In  the  shaft  next  to  the  periosteum  the  bone  is  soft  and  thickened, 
but  deeper  it  is  hard.  Sections  through  thickened  masses  on  the  flat  bones 
show  a  spongy,  vascular  substance  which  is  soft  enough  to  be  indented 
easily. 

Mia'oscopical  examination  shows  a  marked  increase  in  new  cartilage 
cells  and  increased  vascularity  of  the  proliferating  zone.  The  areas  which 
should  be  calcified  show  large  quantities  of  cartilaginous  tissue  instead. 
The  under-layer  of  the  periosteum  is  very  vascular,  and  again  there  is  a 
great  excess  of  uncalcified  cartilage.  In  the  flat  bones  the  bony  trabeculse 
are  eroded,  and  tlieir  places  taken  by  newly  formed  minute  blood-vessels. 

When  the  rachitic  process  ceases  and  recovery  begins,  this  excessive 
proliferation   stops.      Calcification   and   ossification   of   these   tissues   take 


RACHITIS.  311 

place;  the  enlargements  due  to  the  hyperplasia  are  absorbed,  and  the  bone 
returns  to  a  normal  condition  save  for  any  deformities  that  may  have  re- 
sulted during  the  activity  of  the  rachitic  process. 

Etiology. — Children  that  have  suffered  prolonged  diarrhoeas  or  with 
severe  diseases — like  dysentery,  typhoid,  bronchitis,  and  pneumonia — are 
prone  to  the  development  of  rickets.  Children,  of  syphilitic  parents  and 
those  whose  parents  are  tuberculous  are  more  prone  to  the  development  of 
this  disease.  Von  Eitter,  quoted  by  Professor  Baginsky,  says  that,  in  27 
cases  out  of  71  examined  by  him,  rickets  was  not  only  found  in  the 
children,  but  as  well  in  the  mothers  of  these  same  cases.  Thus  it  is  that 
Kassowitz  and  Schwarz^  have  mentioned  the  existence  of  congenital  rickets. 
These  same  authors  found  that  80  per  cent,  of  children  born  in  the  Vienna 
Lying-in  Hospital  were  rachitic.  This  statement  is  not  so  easily  accepted, 
for  neither  Professor  Baginsky  nor  Virchow  accept  the  same.  Experi- 
mentally, it  has  been  found  as  long  ago  as  1842  by  Chossat  that  when 
lime  is  deducted  from  the  nourishment  of  young  animals  not  only  soft 
bones  result,  but  they  finally  die.  Heitzmann  maintains  that,  if  lactic 
acid  is  introduced  into  the  food  of  young  animals,  the  result  will  be,  first, 
rickets,  and,  later  on,  osteomalacia  will  result  therefrom.  Clinical  investi- 
gations have  shown  that  cases  of  rickets  occur  more  often  during  the  winter 
months;  thus  it  would  seem  that  improper  hygiene  is  one  of  the  factors 
causing  this  disease. 

The  bones  show  the  most  characteristic  result  of  improper  nutrition, 
for  they  are  very  soft  and  spongy.  They  will  yield  to  the  weight  of  the 
body  if  used  in  walking,  and  thus  it  is  that  bow-legs  with  extensive  curva- 
tures form  such  a  prominent  feature  in  showing  the  result  of  using  soft 
bones. 

The  absence  of  human  milk  from  the  diet  of  an  infant  is  one  of  the 
prime  reasons  for  the  development  of  rickets.  "We  therefore  find  more  than 
90  per  cent,  of  all  cases  of  rickets  among  bottle-fed  babies.  Other 
■  contributing  factors  are  the  absence  of  sunshine  and  the  crowding  of 
large  families  into  small  rooms  having  poor  ventilation.  Rickets  will 
occasionally  be  seen  in  the  breast-fed  child  under  similar  conditions.  If  the 
mother  while  nursing  suffers  with  malnutrition,  malaria,  chronic  cough, 
or  with  any  organic  lesion  which  devitalizes  her  body,  then  poor  breast- 
milk  deficient  in  its  nutritive  elements  will  cause  the  baby  to  be  underfed 
and  finally  result  in  rickets. 

Symptoms. — One  of  the  earliest  symptoms  noted  is  constipation.  Head 
sweating  while  feeding,  especially  at  night,  is  an  early  s}Tnptom  of  rickets. 
Eolling  of  the  head  on  the  pillow,  with  occipital  baldness,  pallor  of  the  skin, 
and  profound  anasmia,  frequently  precede  or  accompany  the  development 
of  rickets.    Eachitic  changes  affect  the  fontanel  and  the  sutures,  as  well  as 


^  Wiener  medicinisclie  Jahrbucher,  1887,  vol.  viii. 


313  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

all  the  bones  of  the  cranium.  The  rhombic  form  assumes  an  irregular  out- 
line.   The  sutures,  especially  the  lambdoidal  and  frontal,  are  distended. 

The  fontanel  remains  open  much  longer  than  in  normal  infants,  so 
that  not  infrequently  the  anterior  fontanel  can  still  be  felt  slightly  open 
as  late  as  the  third  or  fourth  year  of  life.  Although  the  usual  type  of 
rachitic  head  is  square,  not  infrequently  it  assumes  an  asymmetrical  form. 

We  are  indebted  to  Elsasser  for  a  description  of  one  of  the  most  valu- 
able symptoms  in  rickets,  namely,  "softening  of  the  cranial  bones,"  Imown 
as  ^'^craniotabes."  Small  areas  of  softened  bone  which  will  yield  on  the 
slightest  pressure  can  be  felt  in  the  region  of  the  lambdoidal  suture. 

Early  symptoms  of  rickets  also  are  tetanic  seizures,  muscular  spasms, 
and  laryngeal  spasms.     Dentition  is  delayed,  the  teeth  appearing  irregu- 


Fig.  88. — Rachitic  Ribs.     Incurvation  of  the  ribs  at  the  osseous-cartilaginous 
junction  in  rickets.    One-half  natural  size.     ( Langerhans. ) 

larly,  and  in  older  children  they  are  carious.  Not  infrequently  we  find 
no  evidence  of  teeth  until  the  child  is  16  or  18  months  old.  Eachitic  symp- 
toms appear  later  in  the  thorax  than  in  the  head,  although  they  can  be 
plainly  made  out  during  the  first  six  months.  Beaded  ribs  are  especially 
prominent  in  advanced  cases.  There  is  a  marked  depression  of  the  thorax 
in  a  line  parallel  with  and  on  either  side  of  the  sternum.  This  line  cor- 
responds with  the  course  of  the  beads.  The  so-called  pigeon-breast  or 
funnel-breast  (pectus  carinatum)  is  frequently  observed  in  rickets. 

The  veins  of  the  scalp  are  usually  enlarged.  Spinal  rickets  is  espe- 
cially characteristic.  The  posterior  curve  of  the  spine  is  commonly  known 
as  rachitic  kyphosis.  It  extends  from  the  middle-dorsal  to  the  sacral 
region. 

This  kyphosis  has  been  found  in  more  than  one-half  of  my  cases.  The 
curve  can  be  lessened  or  it  will  disappear  when  the  child  is  placed  on  its 
back  and  extension  is  made  on  the  extremities.  The  more  important 
rachitic  deformities  are: — 


RACHITIS. 


313 


Fig.   S!). 


Fi".   '.to 


Fig.  91.  iMjr.  !)2. 

Illustrating  Rachitic  Erosions  of  the   Permanent  Teeth. ^ 


^  I  am  indebted  to  Dr.  Hugo  Neumann,  Privat-dozent  in  Berlin,  for  the  above 
illustrations. 


314 


DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 


Eachitic  kyphosis. 
Eachitic  scoliosis. 
Chicken  (or  pigeon)  breast. 
The  rachitic  pelvis. 
Cubitus  valgus  or  varus. 
Distortion  of  the  lower  extremities : — 
(a)   Genu  varum. 


Fig.  94 


Fig.  93 


^    V 


Fig.  93. — Five-week-old  Fracture  of  the  Humerus,  in  a  Rachitic  Child 
1%  years  old.      (Langerhans.) 

Fig.  .94. — A  severe  Type  of  Rickets  With  Enlargement  of  Both 
Condyles  of  the  Femur.  There  is  also  enlargement  of  the  upper  epiphyses 
of  the  tibia  and  fibula.  The  illustration  also  shows  enlargement  of  the 
epiphyses  of  the  ankles.  An  anteroposterior  curvature  (giving  the  bow-leg 
appearance)  is  plainly  seen.  Note  also  the  enlarged  epiphyses  of  the  radius 
and  ulna.     Drawn  from  a  photograph.      (Original.) 


(h)   Genu  valgum. 

(c)  Anterior  curvature  of  the  tibiae. 

(d)  General  distortions  of  the  lower  limbs. 


RACHITIS. 


315 


Diastasis  of  the  Recti  Muscles  in  Riclcets. — When  the  muscles  lose  their 
tone,  we  frequently  have  the  bony  changes  soon  afterward.  Diastasis  of  the 
recti  muscles  of  one-half  or  one  inch  can  sometimes  be  made  out.  To  prop- 
erly examine  a  child  for  this  condition  it  should  be  laid  on  its  back  with  the 
head  and  shoulders  elevated;  thus  the  recti  muscles  will  relax  and  a  pro- 
trusion of  the  abdominal  contents  in  the  median  line  can  be  noted. 


Fig.  95. — Case  of  Rickets  Showing  Enlarged  Spleen;   also  Pendulous 
Belly.     (Original.) 


The  clavicle  is  affected  only  in  severe  cases. 

Extremities. — It  is  not  difficult  to  note  deformities  in  the  humerus. 
The  epiphyses,  as  in  all  long  bones,  are  thickened  and  enlarged.  The 
thickening  of  the  epiphyses  in  the  radius  and  ulna  is  readily  made  out. 
The  shafts  of  these  bones  describe  a  convexity  upon  their  extensor  surface. 
Green-stick  fractures  are  very  common  in  these  bones.  The  ends  of  the 
metacarpal  or  of  the  phalanges  are  sometimes  enlarged. 


316  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

The  Lower  Extremities.- — The  outward  bend  of  the  tibia  and,  in  marked 
cases,  of  the  femur  produce  the  condition  known  as  bow-legs  (genu  varum) . 
(Fig.  94.)  In  these  cases  when  the  feet  are  put  together  the  knees  are  far 
apart.  The  opposite  condition  known  as  knock-knee  (genu  valgum)  may 
exist.  The  inner  condyles  of  the  femur  are  hypertrophied,  so  that  when 
the  knees  are  put  together  the  feet  are  far  apart.  Knock-knees  are  more 
common  in  females.  The  ligaments  around  the  joints  are  relaxed  and 
weakened,  so  that  from  an  anatomical  standpoint  they  assist  in  producing 
this  deformity.  The  muscles  show  marked  evidences  of  this  disease.  They 
are  flabby,  soft,  and  small  with  poor  development.  This  accounts  for  the 
lateness  in  walking.  The  muscular  power  is  very  feeble,  and  not  infre- 
quently paralysis  will  be  suspected  when  really  we  are  dealing  with  ag- 
gravated rachitic  muscles. 

Malnutrition  is  plainly  made  out  on  studying  those  emaciated,  anaemic 
children  whose  bones  are  markedly  rachitic.  On  the  other  hand,  we  fre- 
quently find  very  fat  children  with  extreme  pallor  showing  marked  rickets. 
Therefore,  a  fat  infant  is  not  necessarily  a  healthy  infant.  The  abdomen 
is  enlarged  and  usually  tympanitic  on  percussion.  It  is  commonly  known 
as  the  "pendulous  belly."  This  latter  symptom  I  met  with  in  fully  90 
per  cent,  of  my  cases  in  a  large  children's  service  extending  over  many 
thousand  cases.  I  have  rarely  failed  to  note  the  distended  belly  in  rickets. 
The  loss  of  tone  in  the  abdominal  muscles,  and  especially  in  the  muscular 
walls  of  the  stomach  and  intestines,  is  one  of  the  prime  reasons  for  con- 
stipation. Occasionally  the  reverse  may  be  true  and  diarrhoea  may  be 
noted.  There  is  frequently  marked  distention  of  the  stomach  and  colon. 
The  stools  are  hard  and  dry,  causing  a  chronic  catarrh  of  the  colon.  We 
frequently  find  at  the  end  of  the  stool  a  large  amount  of  glairy  mucus. 

The  pulse  and  temperature  are  normal.  Occasionally  a  bruit  can  be 
heard  over  the  anterior  fontanel.  It  has  no  special  significance.  There 
ife  nothing  characteristic  in  the  urine  in  rickets.  The  blood  has  been 
studied  by  Morse,  who  concludes  that  anaemia  is  present  in  most  cases. 
■Its  intensity  varies  with  the  intensity  of  the  rachitic  process.  Leucocytosis 
may  or  may  not  be  present.    An  enlarged  spleen  is  met  with  in  these  cases. 

Convulsions  and  spasms  of  various  descriptions  occur  frequently  in 
rickets.  There  seems  to  be  a  predisposition  to  general  tetany,  and  to  laryn- 
geal spasm  (spasmophilia).  The  general  weakness  of  the  body  is  also 
seen  in  the  marked  tendency  to  irritation  in  the  nerve  centers.  Most 
diseases  in  rachitic  children  are  ushered  in  with  convulsions,  thus  showing 
the  extreme  sensitiveness  and  susceptibility  of  the  nei-ve  centers.  An 
overloaded  stomach  in  a  rachitic  child  under  1  year  of  age,  suffering  with 
high  fever,  is  usually  attended  with  hyperpyrexia  and  convulsions. 

Diagnosis. — This  is  usually  very  easy.  Head  sweating,  constipation, 
restless  at  night,  delayed  dentition  without  palpable  osseous  manifesta- 


RACHITIS.  317 

tions  usually  mean  rickets.  The  most  prominent  symptoms  are  beaded 
ribs,  enlargement  of  the  epiphyses  of  the  wrists  and  ankles,  kyphosis  of 
the  spine,  and  bow-legs. 

Differential  Diagnosis. — The  rachitic  head  is  sometimes  mistaken  for 
hydrocephalus.  The  electrical  reaction  will  decide  whether  or  no  we  are 
dealing  with  a  poliomyelitis,  or  if  the  case  is  a  pseudo-paralysis  with 
rickets.  We  can  differentiate  the  bony  enlargements  of  syphilis  from  rickets 
with  the  aid  of  an  x-ray.  The  hony  changes  in  syphilis  affect  the  shaft 
of  the  hone  rather  than  the  extremities.  An  important  point  to  remember 
is  that  in  syphilis  there  may  be  necrosis ;  this  is  never  seen  in  rickets.  The 
differential  diagnosis  will  best  be  made  by  a  blood  examination  for  the 
presence  of  a  Wassermann  reaction.     Scurvy  is  easily  differentiated  from 


Fig.  9fi. — Rickets,  Showing  Beaded  Ribs  and  an  Enlarged  Pendulous 
Belly.  Mouth-breathing  due  to  adenoids.  Breast-fed  infant.  Always  lived 
in  tenement  house  district.     Mother  very  ansemic.      (Original.) 

rickets  by  the  spongy  condition  of  the  gums,  by  the  tendency  to  haemor- 
rhage, and  usually  also  by  the  presence  of  ecchymotic  spots.  The  diag- 
nosis of  rachitic  kyphosis  from  spinal  tuberculosis  (Pott's  disease)  is 
easily  made,  although  I  have  seen  one  case  in  which  there  existed  a  rachitic 
kyphosis  in  a  tuberculous  child. 

Prognosis  and  Course. — Eickets,  per  se,  is  rarely  fatal.  The  active 
symptoms  exist  about  one  or  two  years;  in  rare  instances  for  many  years. 
Damage  of  the  system  may  remain  throughout  life.  Spinal  curvatures  and 
thoracic  deformities  will  remain  for  many  years. 

Eachitic  children  when  attacked  by  infectious  diseases  suffer  far  more 
and  the  prognosis  is  graver  than  it  would  be  otherwise.  The  abnormal 
condition  of  the  thorax  in  rachitic  children  must  always  be  taken  into 
consideration  in  a  child  suffering  with  pneumonia,  pleurisy,  or  other  pul- 
monary conditions,  in  estimating  the  outcome  of  the  disease. 


318 


DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 


Treatment. — Hygienic  Treatment:  When  rachitic  conditions  are  estab- 
lished the  first  thing  to  do  is  to  insist  upon  removing  such  children  to 
healthful  surroundings.  When  children  are  housed  in  poorly  ventilated 
homes,  dark  rooms,  it  is  useless  to  give  medicine  until  the  unsanitary  sur- 
roundings are  improved.  Successful  treatment  in  such  cases  demands  plenty 
of  sunshine,  open  windows,  night  and  day,  a  tub  bath  with  a  handful  of  sea 
salt  added  every  day.  After  the  bath  good  brisk  rubbing  to  stimulate  the 
circulation  is  very  necessary.  A  change  of  air  from  the  city  to  the  country 
is  desirable.  When  we  are  prescribing  for  the  poor  they  should  be  instructed 
to  remain  in  the  park  as  much  as  possible.  The  establishment  of  small  roof 
gardens  on  the  tops  of  the  highest  dwelling  or  tenement  houses  makes  a 
cheerful  place  for  the  rachitic  children  to  play. 


Fig.  97.— Rickets.    Note  Beaded  Ribs  on  Left  Side  of  Thorax.     (Original.) 

Dietetic  Treatment. — Next  to  hygienic  methods  the  care  of  the  diet 
is  important.  If  a  nursing  infant  shows  rachitic  symptoms  the  chemical 
examination  of  the  breast-milk  should  be  made.  If  we  find  low  proteins 
the  nursing  mother  or  wet-nurse  should  be  given  more  meat,  eggs,  and 
cereals.  If,  however,  conditions  exist  which  prevent  proper  nursing,  the 
child  should  be  weaned.  A  properly  modified  cows^  milk  adapted  for  the 
age  and  development  (see  section  on  "Nutrition")  should  be  substituted. 
I  insist  on  feeding  such  children  with  cereals,  such  as  barley,  rice,  cream  of 
wheat,  sago,  farina,  etc.,  and  giving  them  plenty  of  fresh  vegetables,  such  as 
spinach,  asparagus,  peas,  and  beans.  Eggs,  white  meats,  and  fish  may  be 
given  if  children  are  old  enough.  Fresh  fruits  must  not  be  forgotten. 
Butter  and  cream  are  valuable  adjuncts  to  the  dietary. 

Medicinal  Treatment. — In  addition  to  the  importance  of  proper  feed- 
ing we  must  seek  to  establish  proper  metabolism.  All  the  emunctories 
must  be  carefully  watched.  Drug  treatment  should  be  directed  to  supply- 
ing the  deficient  amount  of  lime  in  the  bones.     The  glycerophosphate  of 


RACHITIS. 


319 


lime,  which  has  been  used  by  me  for  several  years,  in  doses  of  1  to  5  grains, 
three  times  a  day,  is  very  useful.  Codliver-oil,  to  which  Voqo  grain  of 
phosphorus  is  added,  has  served  me  very  well  in  some  instances.  This 
phosphorized  codliver-oil  must  be  freshly  prepared,  as  it  deteriorates  on 
standing.  Hundreds  of  children  in  the  crowded  sections  of  the  city  have 
been  put  on  the  phosphor  treatment.  When  codliver-oil  was  added  to  the 
phosphor,  good  results  were  noted,  not  otherwise ;  so  that  I  believe  it  is  the 
codliver-oil   rather   than   the   phosphor   that   possesses   medicinal    virtues. 


WM 

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i'i^.  y-i  Fig.  99 

Fig.  98. — Rachitic  Kyphosis  (Spine).  Permanent  deformity.  Rachitic 
thorax  in  school  girl,  12  years  old,  showing  Harrison's  groove,  and  funnel- 
shaped  depression  of  sternum. 

Fig.  99. — Back  View  Same  Child,  Showing  Rachitic  Kyphosis.  Tliis 
deformity  is  the  permanent  result  of  rickets  in  infancy.  It  is  to  be  differ- 
entiated from  Pott's  disease.  Note  also  the  curvature  of  the  spine. 
(Original.) 

Fellow's  syrup  of  hypophosphites,  arsenic,  iron,  and  strychnine  have  served 
me  very  well,  especially  when  atony  of  the  stomach  or  dyspeptic  conditions 
existed.  The  careful  regulation  of  the  bowels  and  good  action  on  the  part 
of  the  kidneys  and  skin  will  greatly  aid  in  modifying  rickets  when 
established. 

Treatment  of  Deformities. — Kyphosis:  In  rachitic  kyphosis  a  Brad- 
ford frame  or  a  similar  appliance  is  indicated.  A  spinal  brace  will  some- 
times do  good.    Massage  with  good  friction  will  develop  a  weakened  spine 


320  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

in  some  cases,  and  plaster  of  Paris  jackets  may  be  serviceable.  Manual 
correction  of  the  deformity  will  aid  in  the  treatment. 

History  of  Rickets  in  Infancy. — A  very  ansemic,  poorly  developed  girl.  Brought 
up  in  a  tenement  house  in  the  thickly  crowded  portion  of  New  York  City.  Was 
breast-fed  during  infancy,  fifteen  months.  Had  summer  complaint.  Dentition  began 
at  eight  months,  walking  at  sixteen  months.  Very  bright  mentally.  Is  very 
restless  at  night;  nervous,  choreic  twitching  during  the  day.  No  mammary  develop- 
ment, no  evidence  of  menstruation. 

Father  and  mother  of  this  child  are  apparently  well,  though  dyspeptic.  No 
evidence  of  syphilis  or  tubercular  disease.  This  child  has  had  tonsillar  infections 
several  times  each  year;  had  diphtheria,  measles,  and  scarlet  fever.  Has  diarrhoea 
whenever  nervous  or  frightened. 

Since  instituting  gymnastic  exercises,  the  muscles  of  the  back  have  been 
greatly  strengthened,  although  the  spinal  deformity  has  not  been  lessened  or 
improved. 

The  main  treatment  consisted  in  fresh  air,  out-of-door  exercise,  diet  of  milk, 
cream,  butter,  fruits,  cereals,  and  meats.     Stop  school  and  all  studies. 

Medication,  codliver-oil,  malt,  glycerophosphate  of  lime  and  soda,  raw  eggs. 
Cool  sponging  with  sea  salt.     Friction  of  body  after  gymnastic  movements. 

Scoliosis  {Lateral  Curvature)  and  Lordosis  {Forward  Curvature  of 
the  Spine). — The  management  of  these  conditions  is  similar  to  that  de- 
scribed for  kyphosis. 

Cubitus,  Varus,  and  Valgus. — ^These  deformities  disappear  as  a  rule 
without  special  treatment. 

BoiD-legs  {Genu  Varum). — This  common  rachitic  distortion  may  be 
congenital  or  it  may  be  an  acquired  condition.  The  treatment  consists  in 
support  and  correction  by  braces. 

Whitman  believes  that  correction  by  osteotomy  or  osteoclasis  is  neces- 
sary when  children  are  over  5  years  of  age.  For  knock-knees  braces  are 
usually  necessary.  The  Thomas  knock-knee  brace  is  the  most  efficient.  In 
some  cases  osteotomy  of  the  femur  just  above  the  epiphyseal  line  is  indi- 
cated. 

Antero-posterior  how-leg  can  only  be  corrected  by  osteotomy. 

Genu  Recurvatum  {B'ach-hnee) . — Whitman  states  that  in  its  most 
extreme  form  it  is  of  congenital  origin,  and  is  usually  associated  with 
defective  development  of  the  anterior  thigh  muscles  and  of  the  patella. 
In  such  cases  the  knee  is  bent  directly  backward,  and  the  tibia  is  often  dis- 
placed forward  upon  the  femur.  In  the  milder  types  of  back-knee  there 
is  simply  an  abnormal  or  over-extension  caused  by  laxity  of  the  ligaments 
and  supporting  muscles.  This  form  is  usually  secondary.  It  is  often  seen 
in  cases  of  hip  disease  after  prolonged  mechanical  treatment.  It  may  be 
associated  with  congenital  talipes,  or  it  may  be  the  direct  result  of  paral- 
ysis of  the  muscles  of  the  legs,  or  even  of  general  weakness,  as  in  severe 
rachitis. 

The  following  are  the  principal  points  in  the  differential  diagnosis  of 
rickets  and  Pott's  disease : — 


DECOMPOSITION.  321 

Table  No.  38. 
Rickets.  Pott's  Disease. 

Deformity  not  angular.  Angular. 

Result  of  posture.  Result  of  lesion. 

Evidences  of  rickets  elsewhere.  Absent. 

In  infancy.  Usually  later. 

In  middle  and  lower  part  of  the  spine.  In  any  part. 

The  body  may  be  bent  forward  with-  Forward  flexion  causes  pain, 
out  discomfort. 

The  curve  is  lessened,  or  it  may  be  Never  disappears, 
obliterated  when  the  trunk  is  ex- 
tended. 

Surgical  Treatment. — It  is  always  safe  advice  to  consult  a  surgeon  or 
orthopaedist  concerning  deformities  in  early  life.  Very  many  rachitic  de- 
formities due  to  softened  diaphyses  can  be  corrected  or  modified  as  de- 
scribed in  the  treatment  previously  given.  When  a  brace  appears  unsatis- 
factory, then  surgery  may  yield  excellent  service,  but  surgery  must  be  used 
in  conjunction  with  proper  nutrition  and  restorative  treatment  to  secure 
permanent  benefit. 

Decomposition  (Infantile  Atrophy;  Marasmus,  or 
Wasting  Disease). 

If  the  symptoms  of  dyspepsia  are  prolonged  there  is  a  marked  decrease 
in  weight.  In  addition  thereto  there  is  a  marked  disturbance  of  the 
thermic  center,  and  the  previous  febrile  temperature  gives  place  to  a  sub- 
normal temperature.  The  pulse  is  slow,  the  respiration  irregular,  and  the 
food  tolerance  is  greatly  reduced.  The  gravity  of  this  condition  must  be 
apparent  because  of  the  constant  loss  of  weight. 

The  condition  is  met  with  as  a  result  of  malassimilation  of  food.  It  is 
really  a  deficient  metabolism,  and  results  in  a  gradual  decline.  It  is  impor- 
tant to  note  that  constitutional  disorders,  such  as  tuberculosis  or  syphilis, 
are  not  the  causative  factors.  A  von  Pirquet  test  should  be  made  to 
differentiate  this  condition  from  tuberculosis. 

Etiology. — The  condition  is  caused  by  improper  feeding,  such  as  to  fre- 
quent feeding  of  high-fat  foraiulffi.  By  far  the  greater  number  of  cases  of 
atrophy  are  found  in  bottle-fed  infants.  An  occasional  case  may  occur  as 
the  result  of  faulty  human-milk  feeding.  If  we  meet  with  a  case  of  atrophy 
in  a  breast-fed  infant,  the  thing  to  do  is  to  have  a  chemical  examination 
made  of  the  breast-milk.  If  it  is  found  deficient  in  qualit)',  we  must  with- 
draw it  and  substitute  bottle-feeding.  If  we  wish  to  discard  the  mother's 
milk  for  some  reason,  it  is  advisable  to  secure  a  wet-nurse.  The  removal 
of  such  cases  from  the  breast  to  the  bottle  or  from  the  bottle  to  the 
human  breast  may  be  necessary  to  save  life. 

21 


322 


DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 


The  true  pathology  seems  to  be  a  failure  to  assimilate  food  in  infants 
with  improper  hygiene,  and  as  a  result  progressive  emaciation  takes  place. 

Symptoms. — When  infants  suffer  with  vomiting  or  diarrhoea,  and  this 
condition  is  allowed  to  become  chronic,  then  colic  and  flatulence,  associated 
with  constipation,  supervene,  and  the  result  is  a  gastrointestinal  catarrh. 
Neglect  of  this  condition  means  the  development  of  the  condition  known 
as  atrophy.  The  infant  does  not  thrive,  commences  to  waste,  and  unless 
we  realize. the  condition,  and  give  the  proper  treatment,  the  infant  will  die 


Fig.  109. — Decomposition.  The  loss  of  fat  causes  the  skin  to  hang 
in  loose  folds.  Note  the  left  forearm  and  both  legs.  The  forehead  is 
wrinkled.  The  hand  in  the  mouth  is  a  characteristic  symptom  of  starvation. 
(Original.) 


from  exhaustion  and  inanition.     When  these  cases  linger  for  months  they 
develop  rickets.    Eecovery  without  treatment  is  impossible. 

Prognosis  and  Course. — The  course  of  this  condition  depends  on  the 
amount  of  nutrition  that  can  be  assimilated.  The  worst  forms  of  marasmic 
infants  will  frequently  gain  in  weight  when  proper  food  is  given.  If  the 
appetite  is  poor  a  decided  change  of  air,  from  the  city  to  the  country,  or 
vice  versa,  will  strengthen  the  infant  and  restore  the  appetite.  Many  an 
infant's  life  has  been  saved  by  a  trip  to  the  seashore  or  a  sea  voyage.  The 
outcome  of  the  case  depends  on  judicious  feeding,  a  change  of  air,  and 
proper  hygienic  management. 


DECOMPOSITION.  323 

Treatment. — If  high-fat  formulae  have  caused  this  condition,  the  treat- 
ment consists  in  lowering  the  fat  percentage  of  the  food.  Such  cases  will 
do  well  on  skimmed  milk.  When  skimmed  milk  is  given,  no  sugar  should 
be  added.  It  is  difficult  to  lay  all  blame  on  the  cream,  top-milk,  or  high-fat 
formulae,  especially  if  sugar  has  been  added.  In  some  cases  omitting  the 
sugar  from  the  food  will  be  sufficient ;  other  cases  require  that  both  fat  and 
sugar  be  discontinued  for  a  number  of  weeks  or  until  a  tolerance  for  a  small 
amount  of  fat  and  sugar  has  been  established. 

It  is  in  this  class  of  cases  that  the  albumin  milk  or  eiweiss  milch  of 
Finkelstein  renders  such  good  service.  By  feeding  6  to  8  ounces  of  this 
food  every  four  hours  for  several  weeks,  the  foetid  odor  of  the  stools  will 
disappear  and  they  will  gradually  assume  normal  conditions.     During  suc- 


Fig.  101. — Infantile  Atrophy.  The  emaciation  is  seen  on  the  neck, 
right  arm,  the  thighs,  and  legs.  The  tendons  on  the  right  foot  are  plainly 
seen.     (Original.) 

cessful  treatment  with  albumin  milk  we  must  not  expect  a  gain  in  weight. 
As  long  as  the  fat  and  especially  sugar  is  withheld  we  cannot  expect  a  gain 
in  weight. 

Albumin  milk  is  prepared  as  follows:  A  tablespoonful  of  Simon's 
essence  of  rennet  (or  2  tablets  of  rennet)  is  added  to  1  quart  of  milk,  which 
is  then  placed  in  a  water-bath  of  107°  F.  for  one-half  hour.  It  is  then 
filtered  slowly  by  gravity  without  any  pressure  for  about  one  hour  through 
cheesecloth.  The  coagulum  is  then  washed  twice  in  1  pint  of  water  through 
a  very  fine  sieve  and  forced  through  by  means  of  a  wooden  spoon;  then  1 
pint  of  buttermilk  is  added.    The  chemical  analysis  of  the  food  shows : — 

Albumin  Milk  Coics'  Milk 

Protein    3.00  3.00 

Fats    2.50  3.50 

Carbohydrates    1.50  4.50 

Ash 0.50  0.70 


324  DISORDERS  RESULTING  FROM  IMPROPER  NUTRITION. 

The  theory  as  to  the  difficult  digestibility  of  cows'  milk  casein  is  a 
thing  of  the  past.  Casein,  as  first  shown  by  the  teachings  of  the  Breslau 
school,  is  readily  digested,  even  by  infants  with  serious  digestive  disorders. 

The  whey  experiments  have  proven  that  the  milk  sugar  in  correlation 
with  the  whey  salts  are  the  primary  disturbing  factors,  the  ensuing  abnormal 
milk-sugar  fermentation  causing  faulty  fat  digestion. 

The  high  percentage  of  casein,  in  correlation  with  the  reduced  whey 
salts  and  milk-sugar,  counteracts  the  fermentative  processes  in  the  intestinal 
canal.  Furthermore,  it  allows  the  feeding  of  a  comparatively  high  percent- 
age of  fat.  The  carbohydrates  should  be  increased  by  gradual  addition  of 
dextrimaltose. 


PART  V. 

DISEASES  OF  THE  HEART,  LIVER,  SPLEEN,  PANCREAS, 
PERITONEUM,  AND  GENITO-URINARY  TRACT. 


CHAPTER  I. 

INTRODUCTORY. 

The  Heart  and  Fcetal  Circulation. 

The  circulation  of  the  blood  during  the  whole  fuetal  period  of  ante- 
natal life  is  the  same.  From  the  third  to  the  tenth  month  the  circulation 
is  known  as  "placental,"  and  during  the  intervening  months  it  undergoes 
no  marked  modifications. 

According  to  Ballantyne/  during  the  neo-foetal  period,  it  is  true  the 
circulation* is  that  of  the  chorion;  but  b}^  the  end  of  it  there  has  been  a 
specialization  of  the  circulatory  function,  and  the  blood,  instead  of  being 
sent  to  the  villi  over  a  wide  expanse  of  chorionic  surface,  is  now  directed 
solely  to  those  found  over  one  part  of  it,  that,  namely,  which  is  in  contact 
with  the  decidua  serotina,  the  site  of  the  developing  placenta.  From  the 
end  of  the  neo-foetal  period  onward  to  the  moment  of  birth,  there  is  the 
circulation  of  the  placenta. 

The  essential  peculiarity  of  the  placental  circulation  is  the  sending  of 
the  foetal  blood  out  of  the  fcetal  body  to  a  specially  prepared  and  extra- 
corporeal organ  (the  placenta)  for  purposes  of  oxygenation  and  other  less 
understood  chemical  changes.  This  entails  simply  the  presence  of  an 
efferent  vessel  (or  vessels)  to  carry  the  blood  to  the  extra-corporeal  organ 
and  of  an  afferent  vessel  to  bring  it  back  again. 

Changes  at  Birth. — When  the  umbilical  cord  is  ligated  there  is  an 
interruption  of  the  circulation  through  the  umbilical  vein  and  arteries,  so 
that  in  about  ten  days  after  birth  the  circulation  loses  its  foetal  type  and 
assumes  extra-uterine  conditions. 

The  following  physiological  changes  occur: — 

(a)  The  conversion  of  the  ductus  arteriosus. 

(&)  The  ductus  venosus  into  fibrous  cords. 

(c)  The  closure  of  the  foramen  ovale. 

(d)  Changes  in  the  umbilical  veins  and  umbilical  arteries,  the  fii-st 
forming  the  round  ligament  of  the  liver,  the  second  the  true  anterior  liga- 
ment of  the  bladder  and  the  superior  vesical  arteries. 


^  For  those  interested  I  would  advise  reading  Ballantyne's  book  on  ante-natal 
pathology  and  hygiene. 

(325) 


326 


THE  HEART  AND  FCETAL  CIRCULATION. 


For  some  weeks  before  birth  the  circulation  through  the  foramen  ovale 
is  slight,  it  being  gradually  obstructed  by  the  growth  of  a  septum  which 
nearly  fills  the  space  at  birth.  After  the  first  week  of  extra-iiterine  life, 
very  little  if  any  blood  passes  through  it,  although  complete  closure  of  the 
foramen  often  does  not  take  place  until  the  middle  of  the  first  year.  In 
one-fourth  of  the  autopsies  Holt  made  upon  infants  under  six  months  of 
age,  minute  openings  at  the  margin  of  the  foramen  ovale  were  found.  They 
were  usually  oblique,  and  closed  by  the  valvular  curtain  so  as  to  effectually 
obstruct  the  current  of  blood.  The  ductus  arteriosus  is  first  closed  by  a 
clot,  which  becomes  organized  and  blends  with  the  products  of  a  proliferat- 


Fig.  102  Fig.  103  Fig.  104 

Fig.  102. — ^Note  the  Position  of  the  Apex  Beat  in  a  Very  Young 
Infant;  during  the  first  year  it  is  very  high,  between  the  fourth  and  fifth 
intercostal  spaces.     It  is  most  often  in  the  fourth. 

Fig.  103.— The  Apex  Beat  in  a  Child  About  6  Years  Old.  It  is  lower 
than  in  an  infant.    Usually  found  at  the  fifth  intercostal  space. 

Fig.  104. — The  Apex  Beat  in  a  Child  About  12  Years  of  Age  is  found 
between  the  fifth  and  sixth  intercostal  space. 

The  heavy  black  lines  denote  the  area  of  relative  dullness.  The  small 
shaded  areas  denote  the  area  of  absolute  dullness,     (After  Unger.) 

ing  arteritis.     It  is  rarely  found  open  after  the  tenth  day,  and  by  the 
twentieth  it  is  almost  invariably  obliterated. 


The  Heart.^ 

Size  of  the  Heart. — The  relative  size  of  the  heart  is  greater  in  children 
than  in  later  life.    It  is  smallest  about  the  seventh  year. 

Table  No.  39.— Weight  of  the  Heart  (Boyd). 
Age  Grams. 

At  Ijirth 20.6 

One  and  one-half  years  44.5 

Three  years    60.2 

Five  and  one-half  years 72.8 

Ten  and  one-half  years   122.6 

Seventeen  years 233.7 

^  Heart  murmurs  are  described  on  page  330. 


THE  HEART.  327 

The  anatomical  differences  in  the  child  are : — 

(a)  A  more  horizontal  position  of  the  heart  than  in  the  adult. 

(&)   The  diaphragm  being  higher,  the  heart  is  higher  in  the  thorax. 

(c)  The  ribs  in  a  child  are  more  horizontal  than  in  the  adult. 

(d)  The  liver  in  young  children  is  larger  than  in  adults,  and  as  the 
heart  is  in  close  contact  with  the  liver  the  area  of  cardiac  dullness  merges 
into  that  of  the  liver  dullness  below. 

Tension. — The  degree  of  contraction  of  the  vascular  muscles  deter- 
mines the  size  of  the  artery  and  (to  a  great  extent)  the  tension  of  the 
blood  within  it.  But  if  the  heart  is  acting  feebly  there  may  be  so  little 
blood  in  the  arteries  that  even  Avhen  tightly  contracted  they  do  not  subject 
the  blood  within  them  to  any  considerable  degree  of  tension.  "To  produce 
high  tension,  then,  we  need  two  factors:  a  certain  degree  of  power  in  the 
heart-muscles,  and  contracted  arteries.  To  produce  low  tension  we  need 
only  relaxation  of  the  arteries,  and  the  heart  may  he  either  strong  or  weak. 

"The  pulse  of  low  tension  collapses  between  beats,  so  that  the  artery  is 
less  palpable  than  usual  or  cannot  be  felt  at  all.  Normally,  the  artery  can 
just  be  made  out  between  beats,  and  any  considerable  lowering  of  arterial 
tension  makes  it  altogether  impalpable  except  during  the  period  of  the 
primary  wave  and  of  the  dicrotic  wave,  which  is  often  very  well  marked 
in  pulses  of  low  tension." 

"The  pulse  of  high  tension  is  perceptible  between  beats  as  a  distinct  cord 
which  can  he  rolled  hetiveen  the  fingers,  like  one  of  the  tendons  of  the 
wrist.  It  is  also  difficult  to  compress  in  most  cases,  but  this  may  depend 
rather  on  the  heart's  power  than  on  the  degree  of  vascular  tension.  The 
pulse  wave  is  usually  of  moderate  height  or  low,  and  falls  away  slowly  with 
little  or  no  dicrotic  wave. 

Fig.    105. — Irregular    Pulse,   Low  Tension,    from    a    Case   of    Mitral 
Regurgitation.      (Original.) 

Mode  of  Examination  of  the  Heart. — The  ear  should  be  used,  rather 
than  an  instrument  in  listening  to  the  heart  sounds  in  struggling  children. 
In  children  with  eruptive  fevers  it  is  safer  to  use  a  phenendoscope.  For 
this  purpose  the  Bowles  phenendoscope  (Fig.  106)  is  highly  recom- 
mended, as  it  has  a  flat  attachment  which  can  conveniently  be  placed  in 
the  axilla  or  to  the  posterior  portion  of  the  lung  without  raising  the  child 
from  the  bed.  These  advantages  are  important  inasmuch  as  we  frequently 
can  examine  the  child  while  asleep. 


;328 


THE  HEART  AND  FCETAL  CIRCULATION. 


The  following  aphorisms  are  drawn  from  Crandall : 

1.  The  apex  lies  higher  in  the  chest  and  further  to  the  left  than  in 
the  adult. 


Fig.    106. — Natural  Size  of  Bowles  Stethoscope  for  Examining  Children. 

2.  The  apex  beat  is  hard  to  detect  in  the  infant.  In  the  child  palpa- 
tion shows  this  easier  than  in  the  adult. 

3.  The  area  of  dullness  is  comparatively  large.  (There  are  three 
stages  in  infancy  and  childhood  during  which  differences  are  noted  in  rela- 
tive and  absolute  dullness.)     (See  Figs.  102,  103,  and  104.) 


Fig.    107. — A  Convenient  Stethoscope  for  Children.     Made  by  G-.  Tiemann 
&  Co.  and  by  George  Ermold,  New  York  City. 


4.  Murmurs  are  heatd  over  comparatively  large  areas.  A  study  of 
differences  in  the  quality  of  the  sounds  and  points  of  greatest  intensity  will 
help  us  here. 

5.  The  rate  may  be  increased  and  the  rhythm  altered  by  slight  causes. 

6.  In  rachitic  children  and  in  those  affected  by  empyema  or  pleural 
effusions  and  adhesions  the  apex  may  appear  in  an  abnormal  position. 

7.  Prominence  of  the  precordia  is  sometimes  marked.  Normally  the 
loudest  sound  is  the  first  sound  at  the  apex;  the  weakest  sound  is  the 
second  sound  at  the  aortic  cartilage.     This  accords  with  my  experiencCj 


THE  HEART. 


329 


though  it  does  not  seem  to  be  generally  recognized  that  the  pulmonic  second 
sound  is  in  early  life  stronger  than  the  aortic  sound. 

Table  No.  40 — Classification  of  Cardiac  Diseases. 


Time  of 
Occurrence. 


Intra-uterine 

existence 

or    very 

early    infancy. 


Extra-uterine 

existence 

(infancy  or 

childhood). 


Nature  of  the  Affection. 


{Developmental 
or 
Inflammatory. 

Various  motor  or  sensory 
phenomena  unaccom- 
panied by  sensible 
changes  of  structure. 


Organic, 


Mechanical. 


-  Inflammatory. 


Miscellaneous. 


Olinical  Disease. 


Various  congenital  affections. 


Functional  diseases  of  the  heart. 


Dilatation, 
Hypertrophy, 


Alone  or  as  accom- 
paniment of  in- 
flammatory change. 


Pericarditis,  acute  or  chronic. 
Endocarditis,  acute  or  chronic. 
Myocarditis,  acute  or  chronic. 

Effusions    (non-inflammatory). 

Granulomata. 

Neoplasms. 


-  CHAPTEE  II. 

DISEASES  OF  THE  HEART. 

Eeflex  Symptoms  of  the  Heakt. 

Tachycardia. — Severe  palpitation  of  the  heart  (tachycardia)  fre- 
quently results  from  excitement  or  fright  in  children.  The  heart  on  aus- 
cultation will  be  found  normal,  and  the  only  symptom  noticeable  will  be 
an  exaggerated  pulse-rate  with  an  increase  of  twenty  to  forty  beats  per 
minute.  It  is  usually  a  neurotic  manifestation.  As  a  rule  the  prognosis 
is  good.    The  treatment  consists  in  removing  the  cause  if  possible. 

Bradycardia. — A  slowness  of  the  heart's  action  and  a  slow  pulse-rate 
are  occasionally  met  with  in  children.  It  may  occur  in  health,  although  very 
rarely  without  pathological  significance.  I  have  usually  seen  bradycardia  in 
septic  cases  of  diphtheria  at  my  service  in  the  Willard  Parker  Hospital,  and 
in  the  septic  type  of  scarlet  fever  at  the  Eiverside  Hospital.  When  brady- 
cardia is  seen  during  the  course  of  acute  infectious  diseases  it  should  be 
regarded  as  a  very  serious  symptom  (see  chapter  on  "Diphtheria"). 

Points  to  be  ISToted  in  the  Diagnosis  of  Diseases  of  the  Heart. 

Heart  Sounds  and  Murmurs. 

First  Sound. — In  infections  fevers  there  is  an  increase  in  the  length 
and  intensity  of  the  first  sound  heard  at  the  apex. 

In  continned  fevers  causing  degeneration  of  the  heart  muscles  there 
is  a  shortening  and  weakening  of  the  first  sound  heard  at  the  apex. 

In  exhaustive  heart  strain  seen  in  myocarditis  the  first  sound  is  feeble 
and  merges  into  the  second  sound.  This  condition  is  met  with  in  diph- 
theria, scarlet  fever,  and  typhoid,  although  any  disorder  of  the  body  which 
devitalizes  may  cause  it. 

Fatty  heart,  emphysema,  or  pericardial  effusion  may  give  a  feeble  mitral 
first  sound. 

Pulsus  Paradoxus. — The  heart-beats  during  inspiration  are  more  fre- 
quent, but  less  full,  than  during  expiration.  This  condition  may  be  observed 
in  healthy  children  during  sleep. 

An  irregular  heart's  action  may  occur  during  sleep  in  healthy  children. 
The  heart's  action  is  frequently  influenced  by  inspiration  and  expiration. 

Systolic  Murmurs. — There  are  two  murmurs  possible  for  each  orifice, 
or  eight  in  all.  Of  these,  four,  namely,  mitral  systolic,  mitral  presystolic, 
(330) 


MURMURS.  331 

aortic  systolic,  and  aortic  diastolic,  are  most  likely  to  occur,  with  a  fre- 
quency aljout  in  the  order  of  their  enumeration.  The  necessary  changes 
being  made,  a  like  distribution  applies  to  the  right  side;  although  a  pul- 
monary lesion  is  almost  unknown,  except  as  a  congenital  affection,  while 
disease  of  the  tricuspid  valve  is  less  rare.  . 

Every  murmur  is  determined  by  the  time  of  its  occurrence,  the  direc- 
tion which  it  takes,  and  the  location  of  its  greatest  intensity.  The  blood 
is  driven  from  the  left  ventricle,  during  systole,  through  the  aortic  orifice, 
and,  meanwhile,  all  communication  with  the  auricle  of  this  side  is  cut  off 
by  a  closure  of  the  mitral  valve.  But  should  the  current  encounter  an 
obstacle  at  the  aortic  opening  in  its  onward  course,  it  would  be  thrown  into 
confusion  in  the  aorta,  from  which  a  murmur  would  arise  and  be  carried 
upward.  Hence  this  bruit  is  loudest  at  the  aortic  area,  systolic  in  rh}i;hm, 
and  extends  in  the  direction  of  the  carotids. 

Should  the  mitral  valve  fail  to  close  at  this  time  the  blood  would 
escape  into  the  left  auricle,  as  well  as  run  through  the  proper  channel,  and 
be  set  in  vibration  by  the  impeding  flaps  at  the  mitral  orifice.  Here  the 
bruit  generated  by  this  disturbance  is  borne  with  the  reflux  into  the  auricle, 
and  thence  to  the  back,  and  also  by  conduction  through  the  apex  to  the 
front.  Moreover,  it  is  loudest  in  front  and  at  the  apex,  because  the  heart 
is  nearer  the  anterior  than  the  posterior  surface  of  the  chest.  Therefore, 
this  murmur  is  most  intense  at  the  mitral  area,  systolic  in  rhythm,  com- 
monly diffused  to  the  left,  and  often  audible  near  the  inferior  angle  of  the 
left  scapida. 

In  a  similar  manner  during  systole,  the  blood  is  being  propelled  by 
the  right  ventricle  through  the  pulmonary  aperture,  and  likewise  the  tri- 
cuspid valve  is  closed  or  very  nearly  so.  Thus  supposing  that  an  obstruc- 
tion were  to  occur  at  the  pidmonary  orifice,  there  would  be  a  systolic  mur- 
mur, with  point  of  maximum  intensity  in  the  pulmonary  area  and  extension 
upward  to  the  left,  but  not  into  the  carotids. 

•In  the  event  of  tricuspid  insufficiency,  part  of  the  blood  would  flow 
back  into  the  right  auricle,  and  give  rise  to  a  systolic  bruit,  best  heard  in  the 
tricuspid  area,  and  spreading  uptvard  to  the  right. 

Anaemic  Murmurs. — An  anaemic  munnur  is  always  systolic  in  rhythm, 
loudest  at  the  base  of  the  heart,  and  often  as  audible  in  the  aortic  as  the 
pulmonary  area.  With  ana?mia  pure  and  simple  there  should  be  no  cardiac 
hypertrophy. 

Diastolic  Murmurs.— In  diastole  the  aortic  and  pulmonary  valves  are 
closed,  and  the  auriculo-ventricular  valves  open,  while  blood  is  flowing  from 
the  auricles  to  the  ventricles.  The  vennicular  contraction,  styled  cardiac 
systole,  which  was  initiated  in  the  veins  and  taken  up  by  the  auricles,  has 
gone  through  the  ventricles  and  reached  the  large  arteries,  wherein  the  recoil 
of  the  current  finds  a  point  of  support  at  the  closed  semilunar  cusps. 


332    "  DISEASES  OF  THE  HEART. 

If  tlie  function  of  one  or  more  of  these  cusps  in  the  aortic  valve  be 
destroyed^  each  contraction  of  the  artery  will  drive  a  portion  of  its  contents 
back  into  the  left  ventricle;  and  the  vibrations  generated  in  this  return 
stream  against  the  disorganized  valve  will  cause  a  bruit  that  is  aortic  in 
origin  and  diastolic  in  rhythm. 

Though  this  murmur  of  insufficiency  is  conveyed  along  the  arteries  a 
varying  distance  in  the  efflux,  its  main  direction  is  backward  with  the  reflux ; 
not  so  much  in  the  line  of  the  ventricle  as  down  the  sternum,  owing  to  the 
close  proximity  of  this  bone  to  the  aortic  valves,  and  its  superiority  over 
the  heart  as  a  conducting  medium  of  sound.  The  point  of  maximum  in- 
tensity of  this  hruit  is  more  often  at  the  lower  end  of  the  sternum  than  in 
the  second  intercostal  space.  Granting  that  the  same  thing  could  happen 
to  the  pulmonary  valves,  a  diastolic  murmur  would  he  audible  in  the  pul- 
monary area,  hut  ivith  an  extension  downward  only. 

An  aortic  systolic  munnur  is  loudest  in  the  second  right  intercostal 
space  close  to  the  sternum,  and  a  diastolic  hruit  is  heard  loudest  at  the  loiver 
extremity  of  this  hone.  In  some  instances  these  murmurs  are  heard  only 
at  mid-sternum,  about  on  a  level  with  the  third  costal  cartilages.  In  others 
they  are  most  intense  in  the  second,  and  even  the  third  intercostal  space, 
close  to  the  left  edge  of  the  sternum.  Upon  the  exclusion  of  aneurism,  a 
bruit  within  these  precincts  is  presumably  aortic  and  not  pulmonary,  espe- 
cially if  the  right  ventricle  is  unenlarged. 

Pericardial  Murmurs. — A  pericardial  is  distinguished  from  a  pleuritic 
friction  mainly  by  the  time  and  locality  of  its  occurrence.  Grating  in  the 
pericardium  ohviously  is  limited  to  the  p-cecordial  region.,  and  is  regulated 
hy  the  action  of  the  heart.  That  of  the  pleura,  is  most  prone  to  take  place 
in  the  infra-axillary  regions,  where  pulmonary  mobility  is  extensive.  It  is 
dependent  upon  the  respiratory  movements. 

Venous  Murmurs. — In  quality  venous  murmurs  are  blowing,  cooing, 
and  sometimes  musical;  and  from  the  frequent  resemblance  of  the  noise 
to  that  of  a  humming-top,  it  has  been  denominated  venous  hum. 

It  is  usually  most  distinct  at  the  lower  third  of  the  external  jugular 
veins,  and  more  distinct  in  the  right  than  in  the  left  side.  It  is  always  con- 
tinuous in  rhythm,  but  the  intensity  is  often  remittent  because  of  the 
periodical  acceleration  of  the  stream  by  the  action  of  the  heart.  The  direc- 
tion is  downward  and  inward  along  the  subclavian  and  right  innominate 
veins,  so  that  it  is  now  and  then  audible  through  the  aortic  area,  and  can  be 
separated  with  a  little  care  from  the  aortic  sounds  as  well  as  from  the 
respiratory  murmur.  When  there  is  a  question  as  to  whether  or  not  a  given 
hruit  is  venous  or  arterial,  pressure  upon  the  vein  ahove  the  stethoscope  will 
stop  the  downward  current  and  silence  the  venous  hum. 


PI  LM(  ).\ARV  STKNOSTS. 


33.1 


Cerebral  Blowing. — A  Ijlcwing,  systolic  murmur,  of  variable  intensity, 
is  frtMjuently  lieard  ovlt  the  anterior  fontanel  and  sometimes  over  the 
carotids  of  children,  between  the  ages  of  tliree  months  and  six  years.^ 

Pulmonary  Stenosis  (Congenital  Heart  Lesion:   Blue  Baby). 

A.  N.  H.,  born  Mux  7,  1904,  was  first  seen  by  me  when  seven  months  old,  in 
consultation  with  Dr.  E.  D.  Lederman. 

Family  Hifilory — It  was  the  third  child  born  witli  natural  labor.  The  mother 
has  had  one  still-birth  and  one  miscarriage.    Has  one  child  .5  years  old  in  good  health 


-LOUD  SYSTOLIC 
MURMUR. 


3YST0LIC  MURMUR. 
(very  forcible  thiill 
tiaiismitted  on  palpation.) 


Dotted  inner  line  denotes 
normal  area  of  heart.  Shaded 
line  around  heart — area  of 
cardiac  dullness  on  percussion. 


Fig.    108. — Case  of  Pulmonary  Stenosis — Congenital — Blue  Babv.      (Original.) 


with  no  evidence  of  heart  trouble.  Both  father  and  mother  are  in  excellent  health, 
and  there  is  no  evidence  of  heart  or  lung  trouble,  and  no  specific  disease  on  either 
side.  This  child  has  been  cyanotic.  The  toe  nails  and  finger  nails  show  typical 
clubbing  and  also  blueness.  On  the  slightest  exertion  the  infant's  skin  assumes  a 
very  dark  blue  color.  Dyspnoea  is  also  present.  The  cutaneous  circulation  is  very 
poor  and  the  nurse  informed  me  that  for  one-half  hour  after  a  tub  bath  there  is  an 
increased  evidence  of  cyanosis. 

A  loud  blowing  systolic  nuirmur  could  be  made  out  iu  the  second  intercostal 
space.  There  was  also  a  weakness  of  the  pulmonary  second  sound.  The  area  of 
dullness  was  increased  so  that  a  right-sided  hypertrophy  undoubtedly  existed.  Tho 
muniuir  was  not  transmitted  to  the  vessels  of  the  neck. 

The  infant  was  breast-fed  by  its  mother  for  four  and  one-half  months.  There 
has  been  a  tendency  to  constipation.     The  stool  has  been  green  and  contained  white 


1 1  am  indebted  to  S.  S.  Burt  &  E.  Le  Fevre  for  some  points  in  the  above  article. 


334  DISEASES  OP  THE  HEAKT. 

curds  at  times.  During  the  last  few  months  the  feeding  consisted  of  equal  parts  of 
barley  water  and  milk.  When  seen  again  the  appetite  was  poor.  The  tongue 
slightly  coated.  The  general  condition  one  of  restlessness  by  day  and  insomnia 
by  night.  The  infant  was  very  sensitive  to  cold  and  had  a  diffuse  bronchitis 
associated  with  acute  rhinitis.     I  ordered: — 

^  Raw  milk 12  ounces 

Rice  water 24  ounces 

Granulated  sugar  6  drachms 

Lime  water    6  drachms 

Peptogenic  milk  powder 2  measures 

Divide  in  six  bottles.     Feed  every  3%  hours. 

As  the  food  agreed  very  well,  I  ordered  1   ounce  more  of  milk  to  the  total 
quantity  every  second  day  until  the  infant  received  full  milk  undiluted. 
I  ordered  to  relieve  the  dyspncea  and  regulate  the  heart: — 

IJ  Sodium  iodide  15  grains 

Sparteine  sulphate   3  grains 

Elix.  lactopeptin   2  ounces 

Half-teaspoonful  three  times  a  day. 

The  progress  of  the  case  was  excellent.  When  first  seen  by  me  there  was  no 
evidence  of  dentition.  At  the  ninth  month  the  child  had  two  teeth  and  showed 
signs  of  general  development. 

Prognosis. — As  a  rule  the  outcome  of  these  cases  is  bad,  although  I 
have  known  a  child  with  a  pulmonary  stenosis  for  the  last  twelve  years. 
He  is  now  18  years  old.  These  cases  have  a  tendency  to  pulmonary  disease, 
and  are  especially  prone  to  develop  tuberculosis. 

Treatment. — Peroxide  of  hydrogen  or  dioxygen  in  5-  to  10-  drop  doses 
in  water,  given  several  times  a  da,j,  will  liberate  oxygen.  Some  cases  will 
show  a  rapid  improvement  in  the  cyanosis  during,  this  treatment. 

Persistence  of  the  Ductus  Arteriosus  Botalli. 

During  the  first  four  weeks  after  the  birth  of  an  infant,  the  ductus 
arteriosus  is  closed  by  an  overgrowth  of  the  cells  in  its  inner  wall.  When 
abnormal  conditions  exist,  such  as  septic  infection  of  the  new-born  with 
thrombi,  a  breaking  down  of  the  cell  growth  takes  place  and  results  in  the 
duct  remaining  patent.  This  may  also  result  from  defective  respiration 
and  an  anomalous  pulmonary  circulation. 

The  clinical  symptoms  of  the  patency  of  the  ductus  arteriosus  are 
rapid  hypertrophy  and  dilatation  of  the  right  ventricle,  with  co-existing 
dilatation  of  the  pulmonary  artery.  There  is  also  an  increased  area  of 
cardiac  dullness.  Loud  systolic  murmurs  are  heard  all  over  the  chest,  and 
a  thrill  of  the  anterior  chest  wall  can  be  felt.  Protrusion  of  the  upper  part 
of  the  sternum — dyspnoea  rarely — cyanosis  and  a  deathly  pallor. 

Gerhardt  states  that  dullness  is  found  at  the  border  of  the  second  rib, 
in  which  region  the  systolic  pulsation  of  the  pulmonary  artery  can  be  felt. 


ENDOCARDITIS. 


335 


M.  G.,  four  niontlis  old.  Was  two  weeks  prematurely  born.  She  was  the 
second  child.  The  first  child  died  of  diphtheria;  it  was  also  prematurely  born,  and 
died  when  its  mother  was  four  montiis  pregnant  with  the  present  baby.  The  mother 
had  a  normal  i)regnaney,  l)ut  was  greatly  troubled  with  headaches  and  dizziness,  and 
suffered  mentally  over  the  loss  of  tiie  first  child. 

The  Baby. — When  the  baby  was  six  weeks  old  the  mother  first  noticed  that  it 
breathed  with  difficulty.  It  had  been  vomiting  continuously.  J)iarrhGea  has  existed 
for  ten  weeks.  There  is  an  occasional  cough.  Since  two  weeks  the  baby  appears 
colicky  and  cries  with  apparent  pain. 

fitat.  Pxcs. — ^A  pale,  very  anaemic  looking  child,  with  large  fontanel,  somewhat 
depressed,  the  size  of  a  silver  quarter. 

The  Eyes. — There  was  a  slight  exophthalmus.  The  nose,  somewhat  depressed. 
Slight  coryza. 

The  Heart. — The  area  of  dullness  extends  from  the  right  side  to  the  left  border 
of  the  sternum,  corresponding  to  the  lower  border  of  tlie  third  rib.     Tlie  apex  is 


FRONT 


Fig.    109. — Child  with  Persistence  of  the  Ductus  Arteriosus  Botalli.    Xj  Loud 
murmur  audible — blowing  presystolic.      (Original.) 

at  the  lower  border  of  the  fifth  rib,  immediately  under  tlie  maniilla.  The  lieart  is 
somewhat  enlarged  toward  the  left  side. 

Auscultation. — A  loud  presystolic  murmur  is  heard  over  the  whole  area  of  the 
heart.  There  is  marked  abdominal  respiration.  The  lungs  are  normal  in  percussion. 
Moist  rales  can  be  heard  over  both  lungs. 

The  Abdomen. — The  abdomen  is  distended  and  is  tympanitic  on  percussion.  It 
feels  doughy  on  palpation.  There  is  no  cyanosis  of  the  fingers  or  toes.  There  is 
a  mild  dyspnoea.  The  adipose  tissue  is  not  very  apparent.  There  is  marked 
prominence  of  the  subcutaneous  veins  of  the  scalp. 

The  clinical  liistory  of  the  mother  did  not  give  any  evidence  of  miscarriage, 
no  syphilis,  and  no  family  tuberculosis. 


Endocarditis. 

This  disease  is  of  frequent  occurrence  during  infancy  and  childhood. 
Congenital  endocarditis  has  frequently  been  reported,  so  that  it  is  assumed 
it  must  have  existed  during;  foetal  life. 


336  DISEASES  OF  THE  HEART. 

Etiology. — Gerhardt  and  Bednar  believe  that  the  disease  occurs  quite 
frequently  in  young  children,  although  the  greatest  frequency  is  noted 
between  the  sixth  and  the  twelfth  years.  Acute  rheumatism  is  very  fre- 
quently followed  by  endocarditis.  Chorea  is  also  frequently  accompanied 
by  endocardial  disease.  Scarlet  fever,  measles,  variola,  varicella,  diph- 
theria, typhoid,  and  tuberculosis,  according  to  Eeimer,  are  frequently  fol- 
lowed by  or  associated  with  endocarditis.  When  endocarditis  follows  pneu- 
monia, pleurisy,  or  bronchitis,  it  is  due  to  the  invasion  of  pathogenic 
bacteria.  These  are  the  staphylococcus,  according  to  Frankel  and  Sanger, 
and  the  pneumococcus,  according  to  Netter  and  Weichselbaum.  The  germs 
enter  the  deeper  portion  of  the  pericardium  through  the  epithelium,  causing 
inflammatory  conditions.  It  is  quite  likely  that  endocarditis  is  caused  by 
such  invasion  in  acute  joint  inflammations,  in  phlegmonous  periostitis, 
lymphangitis,  pericarditis,  myocarditis,  and  puerperal  infections.  'Bouchut 
has  reported  cases  of  endocarditis  following  erythema  nodosum  and  hered- 
itary syphilis.  Von  Dusch  has  reported  endocarditis  following  extensive 
burns  of  the  hand. 

Pathology. — ^The  lesions  occur  most  frequently  on  the  valves  of  the 
heart.  The  valves  on  the  left  side  of  the  heart  are  most  frequently  affected ; 
hence,  the  mitral  is  the  seat  of  the  lesions  more  often  than  the  aortic  valve. 
In  studying  a  series,  of  these  cases  given  by  Steffen,  we  find  that  about  4 
per  cent,  show  lesions  in  the  aortic  valve. 

The  pathological  changes  consist  in  hypersemia,  swelling,  and  an 
infiltration  of  normal  cells  or  new  connective-tissue  cells  having  a  grayish- 
white  color.  There  is  a  breaking  down  of  the  epithelium,  besides  which  wart- 
like excrescences  called  vegetations  are  formed  on  the  free  border  of  the 
thickened  valves  (endocarditis  verrucosa).  The  result  caused  by  the  last- 
named  condition  is  that  the  vegetations  prevent  a  proper  closing  of  the  valves, 
which  latter  results  in  insufficiency  and  stenosis.  Fibrinous  deposits  are 
frequently  noted  on  the  valves,  and  on  being  carried  with  the  circulation 
may  lodge  in  the  cerebral  arteries,  causing  either  emboli  or  infarctions, 
according  to  Virchow.  The  last-named  condition  is  exceptional  in  acute 
endocarditis. 

Symptoms. — Endocarditis,  whether  primary  or  secondary,  begins  with 
fever.  Not  infrequently  the  temperature  rises  to  103°,  sometimes  103° 
F.,  and  there  is  a  corresponding  increase  in  the  pulse-rate.  The  pulse  is 
rapid,  irregular,  and  of  low  tension.  Cyanosis  is  sometimes  present,  espe- 
cially so  if  myocarditis  accompanies  the  attack.  Sometimes  a  child  will 
develop  endocarditis  without  any  special  symptoms  being  present.  Not 
until  the  heart  is  examined  will  the  condition  be  diagnosed.  Thus  an 
important  rule  which  has  been  previously  mentioned  is  the  necessity  of 
always  listening  to  the  heart  when  a  diagnosis  is  uncertain.  Frequently 
a  few  days  will  pass  without  specific  symptoms  being  recognized.    A  child 


ENDOCARDITIS.  337 

will  show  evidence  of  malaise  and  suddenly  the  characteristic  blowing  sys- 
tolic murmur  will  be  heard  at  the  apex.  The  murmur  is  usually  trans- 
mitted to  the  left  and  can  also  be  heard  behind.  It  is  frequently  accom- 
panied by  the  thrill  and  by  an  accentuated  pulmonic  second  sound.  When 
dilatation  results  there  will  be  a  cardiac  insufficiency.  The  murmur  may 
gradually  increase  in  intensity  and  in  the  same  manner  it  may  diminish 
until  it  is  inaudible.  When  fever  suddenly  appears  during  the  course  of 
an  attack  of  chorea,  endocarditis  should  be  suspected.  In  some  cases 
dyspnoea  may  be  present. 

The  diagnosis  is  frequently  obscure  because  a  child  will  have  no  symp- 
toms of  a  definite  nature.  If,  however,  we  are  patient  and  carefully  ex- 
amine the  heart,  we  may  be  rewarded  by  making  the  diagnosis.  It  is  im- 
portant to  examine  all  the  organs  of  the  body  before  making  a  positive 
diagnosis,  if  obscure  or  no  cardiac  symptoms  exist. 

A  cardiac  murmur  heard  during  an  acute  attack  of  rheumatism,  or 
during  the  course  of  an  acute  infectious  disease,  is  usually  indicative  of 
endocarditis,  especially  if  on  pressure  with  the  stethoscope  the  murmur 
remains  permanently.  Associated  with  the  murmur  there  is  usually  a  rise 
in  temperature. 

Inspection  will  always  show  a  rapid  and  diffuse  apex-beat. 

Palpation  will  confirm  this  observation  and  may  reveal  a  strong  but 
irregular  heart  action. 

Percussion  is  usually  negative. 

Physical  signs  are  due  to  (a)  insufficiency,  (&)  roughening,  (c)  ste- 
nosis, depending  on  changes  in  the  valves.  The  character  of  the  murmur 
depends  on  the  valve  involved  and  the  lesion  of  the  valve.  In  mitral  regur- 
gitation we  have  a  systolic  murmur  with  greatest  intensity  over  the  apex. 
It  is  usually  transmitted  to  the  side,  and  also  heard  behind  the  sternum. 

Differential  Diagnosis. — In  mitral  stenosis  we  have  a  pi'Csystolic  mur- 
mur with  the  greatest  intensity  over  the  mitral  area. 

In  aortic  regurgitation  we  have  a  diastolic  murmur  with  the  greatest 
intensity  over  the  aortic  valve,  and  transmitted  down  the  sternum. 

In  aortic  roughening  we  have  a  systolic  murmur  with  the  greatest 
intensity  over  the  aortic  valve.  Distinct  murmurs  can  be  heard  at  the 
valves  of  the  right  side. 

An  embolism  in  some  portion  of  the  body  is  frequently  the  sign  of  a 
heart  lesion.  If  the  embolus  reaches  the  brain,  hemiplegia  is  the  usual 
result.  If  it  reaches  the  lungs  severe  dyspnoea  may  result.  An  embolus 
in  the  mesentery  may  result  in  diarrhoea.  If  in  the  kidneys,  hasmaturia  may 
result.    When  it  reaches  the  limbs  it  means  an  obstructed  circulation. 

Prognosis  and  Course. — Endocarditis  if  carefully  managed  with  rest 
and  strengihening  diet  will  improve.  I  have  seen  children  with  endocardial 
murmurs  improve  after  a  few  weeks,  when  put  to  bed  amid  quiet  surround- 

22 


338  DISEASES  OP  THE  HEAKT. 

ings.  As  a  rule  the  prognosis  is  bad  and  the  course  of  the  disease  tends 
to  become  chronic.  In  giving  an  opinion  as  to  the  outcome  of  a  case  of 
valvular  lesion,  we  must  remember  that  we  are  dealing  with  a  damaged 
heart,  and  that  months  or  years  may  pass  before  recovery  can  take  place. 
A  fatal  outcome  will  be  the  result  of  carelessness  or  mismanagement. 

Treatment. — ^^Nothing  will  do  more  good  than  absolute  rest  in  bed. 
Small  doses  of  codein  or  Dover's  powder  act  very  well.  If  endocarditis 
accompanies  or  follows  rheumatism,  then  the  salicylates  should  be  given. 
An  ice-bag  over  the  heart  is  frequently  useful.  If  the  pulse  is  very  rapid 
or  the  heart's  action  is  feeble,  then  digitalis  or  strophanthus  should  be 
given. 

The  tincture  or  an  infusion  of  digitalis  made  from  English  leaves  is 
the  best.  A  point  to  remember  is  that  digitalis  has  frequently  an  accu- 
mulative effect  so  that  the  pulse  must  be  carefully  guarded  during  its 
administration.  When  this  is  the  case  the  administration  of  the  tincture 
of  strophanthus  will  be  found  very  serviceable.  In  some  children  digitalis 
will  be  badly  borne  owing  to  its  irritant  action  on  the  gastric  mucous 
membrane.     In  such  cases  sparteine  or  strophanthus  should  be  prescribed. 

Adrenalin  chloride  solution  taken  internally  increases  the  blood  pres- 
sure, stimulates  the  heart,  and  retards  the  pulse-rate.  It  is  better  than 
digitalis,  as  it  does  not  irritate  the  gastric  mucous  membrane,  and  it  is 
non-cmnulative. 

IJ  Sol.  adrenalin  chloride  1-1000 

Infants  of  1  year,  1-5000,  made  with  normal  saline  solution. 
Dose:     Five  to  10  drops,  three  times  a  day,  gradually  increased  until  eflfect 
on  pulse  is  manifested. 

In  some  cases  marked  benefit  will  follow  the  use  of  iodide  of  sodium 
in  doses  of  1  to  5  grains,  according  to  age.  The  iodides  seem  to  steady  the 
heart's  action.    I  have  found  excellent  results  following  their  use. 

Malignant  Endocakditis. 

This  is  conmaonly  called  ulcerative  endocarditis.  It  is  a  rare  condition 
in  childhood.  Harris  reports  a  case  in  a  child  4  years  old.  The  type  of 
the  disease  is  similar  to  that  noted  in  adults.  This  condition  is  rarely 
primary.  It  occurs  with  scarlet  fever,  erysipelas,  pneumonia,  rheumatism, 
and  septicaemia,  in  which  bacterial  invasions  of  streptococci  or  pneumococci 
occur.    These  germs  are  found  in  the  endocardium. 

Pathology. — Vegetations  usually  occur  with  ulcerations  in  the  cavities 
and  on  the  valves.  Suppuration  of  the  deeper  tissues  with  abscess  forma- 
tion is  frequently  noted.  Osier  states  that  the  different  parts  of  the  heart 
are  affected  in  the  following  manner :  mitral  valve,  aortic,  mitral  and  aortic 
combined,  tricuspid  and  pulmonic  valves,  and  the  cardiac  wall.    The  sec- 


PERICARDITIS.  "  339 

ondary  lesions  of  malignant  endocarditis  are  due  to  emboli.  These  are 
most  frequent  in  the  spleen  and  kidney,  next  in  the  brain,  intestines,  and 
skin,  and,  if  the  right  side  of  the  heart  is  diseased,  in  the  lungs.  These 
emboli  lead  to  the  formation  of  red  or  white  infarctions,  to  haemorrhages, 
or  to  multiple  abscesses  in  the  various  organs  and  tissues  in  which  they 
lodge. 

Symptoms. — It  is  extremely  difficult  to  diagnose  malignant  endocar- 
ditis. The  presence  of  symptoms  of  pyemia  or  septicaemia,  associated  with 
a  heart  murmur,  usually  renders  the  diagnosis  positive.  There  is  a  remit- 
tent type  of  fever,  occasionally  delirium  and  extreme  prostration.  The 
cerebral  symptoms  frequently  suggest  meningitis.  There  is  sometimes  a 
faint  mitral  regurgitant  murmur.  Not  infrequently  it  is  entirely  absent. 
The  spleen  is  usually  enlarged.  Hemiplegia  as  well  as  haematuria  and 
rapid  swelling  of  the  spleen,  or  possibly  symptoms  of  pneumonia,  are  fre- 
quently the  result  of  emboli. 

Diagnosis. — This  is  at  times  extremely  difficult.  An  examination  of 
the  blood  for  plasmodia  will  usually  be  the  means  of  excluding  malaria  if 
the  same  is  suspected. 

Prognosis  and  Course. — The  rapidity  of  the  onset  and  the  malignancy 
of  the  disease  go  hand  in  hand.    The  outcome  is  usually  fatal. 

Treatment. — In  addition  to  rest  and  a  supporting,  stimulating  diet, 
nothing  but  relief  of  individual  symptoms  by  routine  treatment  can  be 
given. 

Pericarditis.^ 

This  disease  may  exist  with  or  without  mj'^ocarditis  or  endocardial  in- 
volvement.   Large  effusions  occur  more  readily  in  children  than  in  adults. 

Etiology  and  Causes. — Rheumatism  is  the  most  frequent  cause  of  peri- 
carditis. Apparent  mild  forms  of  rheumatism,  such  as  are  frequently 
called  "growing  pains"  by  the  laity,  are  quite  often  complicated  by  peri- 
carditis. In  this  manner  the  existence  of  the  rheumatism  preceding  the 
pericarditis  is  strikingly  brought  out. 

Pericarditis  is  rarely  a  primary  condition.  Septic  infection  of  the 
umbilicus  occasionally  causes  this  condition. 

Tuberculosis,  scarlet  fever,  diphtheria,  measles,  typhoid,  and  influ- 
enza frequently  precede  a  pericarditis. 

Baginsky  found  purulent  pericarditis  associated  with  phlegmonous 
erysipelas,  grave  forms  of  angina,  caries  of  the  ribs,  fibrinous  pneumonia, 
bronchopneumonia,  gastroenteritis,  furunculosis,  phlegmon  of  the  throat, 
and  empyema.    It  not  infrequently  follows  kidney  disease  and  scurvy. 

Pericarditis  is  met  with  at  any  age.  It  has  been  met  with  in  the  fcetus, 
according  to  Billard,  Bednar,  Hiiter,  and  Steffen. 


*  The  anatomical  outlines  are  illustrated  and  described  in  the  article  on  "The 
Heart  and  Circulation."     See  "Introductory,"  Part  V. 


340  ^  DISEASES  OP  THE  HEART. 

Bacteriology. — We  most  frequently  meet  with  a  staphylococcus  aureus 
or  streptococci,  bacterium  coli,  and  the  diplococcus  pneumoniae. 

Pathology. — Pericarditis  may  be  divided  into : — 

(a)   Plastic  pericarditis. 

(&)   Pericarditis  with  serous  or  purulent  effusion. 

(c)  Adherent  pericarditis. 

Any  of  the  above-mentioned  varieties  consists  of  an  inflammatory 
affection  involving  the  serous  covering  of  the  heart  and  its  reflection  on 
the  inner  surface  of  the  pericardial  sac. 

Symptoms  and  Diagnosis. — The  acwte  condition  begins  with  fever 
reaching  as  high  as  104°  P.  in  some  instances.  Associated  with  this  there 
is  pain  in  the  prsecordial  region.  Dyspnoea  is  present.  There  may  be  left 
pleurothotonos  (a  bending  of  the  body  to  one  side).  The  pulse  is  usually 
rapid.  When  there  is  effusion  the  child  will  complain  of  either  very  sharp 
pains  or  merely  a  sense  of  heaviness  and  discomfort.  Syncope,  singultus, 
and  severe  manifestations  are  present  in  the  severer  types  of  the  disease. 
Not  infrequently  there  may  be  delirium,  twitching,  and  cerebral  symptoms 
simulating  meningitis.     When  effusions  are  abundant,  cyanosis  may  occur. 

The  physical  signs  resemble  those  of  adults.  In  dry  pericarditis  a 
double  friction  sound  is  heard  over  the  prgecordial  space.  The  friction 
sounds  may  vary  in  intensity.  It  may  be  a  grating  sound  or  it  may  be  a 
weaker  rubbing  sound.  The  friction  sound  or  murmur  is  usually  loudest 
at  the  base  of  the  heart.  Its  intensity  depends  on  the  change  of  position 
so  that  it  is  louder  when  the  child  sits  up  or  when  it  exerts  itself  as  in 
walking  or  bending.  When  the  child  is  quiet  or  lies  on  its  back  the  friction 
sound  is  weaker. 

When  a  large  area  of  the  heart  is  involved,  the  friction  murmur  will 
also  be  heard  with  great  intensity  at  the  apex.  When  a  child  is  placed  in 
the  knee-elbow  position,  the  apex  beat  which  could  not  be  palpated  may 
reappear.    This  is  an  important  symptom  of  exudative  pericarditis. 

The  pericardial  friction  sound  may  be  purely  systolic  at  the  beginning 
of  the  disease;  thus  we  must  differentiate  it  from  an  endocardial  murmur. 
Its  maximum  intensity  is  at  the  base  and  it  is  not  transmitted  beyond  the 
prsecordial  region,  whereas  in  acute  mitral  endocarditis  we  have  the  maxi- 
mum intensity  of  the  systolic  murmur  at  the  apex.  It  is  transmitted  to  the 
side,  and  heard  also  posteriorly  at  the  angle  of  the  scapula.  Priction  sounds 
disappear  as  serum  is  poured  out  and  reappear  as  it  is  absorbed.  The  sound 
is  not  transmitted  and  is  independent  of  the  respiratory  movement.  If 
effusion  takes  place  the  apex-beat  will  be  found  displaced,  sometimes  up- 
ward and  outward  or  indistinct ;  in  some  instances  it  cannot  be  found  at  all. 
There  may  be  bulging  of  the  chest  wall.  The  intercostal  spaces  become 
very  prominent.  On  palpation  there  is  an  absence  of  vocal  fremitus  over  an 
area' usually  occupied  by  the  lung. 


PERICARDITIS.  341 

Percussion  gives  an  area  of  marked  dullness  or  flatness  of  triangular 
shape,  the  base  being  below  and  the  apex  above.  The  normal  area  of  car- 
diac dullness  is  increased  in  all  directions,  and  this  dullness  extends  beyond 
the  limits  of  the  heart.  On  auscultation  the  heart  sounds  are  feeble  and 
distant.  Endocardial  murmurs  may  also  be  present.  In  infants  physical 
signs  are  often  entirely  wanting,  or  the  normal  sounds  may  be  feeble,  dis- 
tant, or  absent. 

The  usual  duration  of  acute  pericarditis  is  from  one  to  three  weeks. 
The  ordinary  dry  form,  with  the  resulting  adhesions,  may  be  followed  by 
a  subacute  or  chronic  form  of  the  disease.  In  the  serofibrinous  form  the 
serum  is  usually  absorbed  quite  promptly,  and  only  adhesions  are  Jeft  or 
a  chronic  inflammation  follows,  with  exacerbations  in  each  recurrence  of 
rheumatism.  In  the  purulent  form  of  the  disease  in  young  children,  death 
is  the  most  frequent  termination.  If  the  pus  is  evacuated  or  spontaneous 
opening  takes  place,  there  may  be  recovery,  but  always  with  more  or  less 
extensive  adhesions  remaining. 

Prognosis. — The  prognosis  should  always  be  looked  upon  as  very  grave. 
Steffen  states  that  out  of  35  cases  only  6  recovered.  When  this  disease 
follows  pyaemia,  or  when  it  is  a  sequela  to  the  acute  infectious  diseases,  the 
prognosis  is  very  bad.  When  it  is  associated  with  rheumatism  the  ultimate 
results,  by  reason  of  adhesions  and  dilatation,  are  usually  very  serious. 

Treatment. — Children  affected  with  acute  pericarditis  should  be  put 
to  bed  and  kept  quiet.  An  ice-bag  placed  over  the  heart  and  small  doses 
of  opium  or  Dover's  powder  seem  to  steady  the  heart's  action.  The  value 
of  aconite  in  this  disease  must  not  be  forgotten,  especially  when  we  have 
excessive  heart's  action.  Very  bad  effects  have  been  noted  by  me  when 
either  pilocarpine  or  jaborandi  was  given.  The  specific  effect  of  salicylate 
of  soda,  salol,  or  salophen  must  be  remembered  if  due  to  rheumatism.  If  the 
salicylates  irritate  the  gastric  mucosa,  then  inunctions  with  salicylic  prepa- 
rations such  as  mesotan  or  rheumasan  may  be  given  three  times  a  day. 
Phenacetin  in  2-  to  3-  grain  doses  may  be  given  every  three  hours  if  the 
child  complains  of  pain  and  if  fever  is  present.  Good  results  may  frequently 
be  had  from  salophen  in  2-  to  3-  grain  doses. 

Aspiration  of  the  Pericardium. — When  symptoms  of  collapse,  cyanosis, 
irregular  pulse,  and  severe  dyspnoea  are  present,  then  aspiration  may  do 
good.  If,  on  aspiration,  we  find  pus  present,  an  incision  should  be  made 
and  drainage  should  be  used  as  we  would  in  a  case  of  empyema.  The  proper 
place  to  puncture  the  pericardium  is  a  point  a  little  to  the  left  of  the 
border  of  the  sternum  in  the  fifth  intercostal  space,  the  needle  being  directed 
upward  and  outward.  It  must  be  remembered  that  by  this  means  only 
can  relief  be  expected.  Keating  states  that  "of  18  cases  punctured  only  4 
recovered." 


343  DISEASES  OF  THE  HEART. 


CimoNic  Pericarditis  with  Adhesions. 

When  children  suffer  with  repeated  attacks  of  rheumatism  complicated 
by  pericarditis,  a  chronic  pericarditis  frequently  remains.  Holt  describes 
a  case  of  a  child  sixteen  months  old  in  which  the  pericardial  sac  was  com- 
pletely obliterated.  Associated  with  this  condition  we  frequently  have 
chronic  myocarditis,  hypertrophy,  dilatation,  and  valvular  lesions,  so  that 
no  portion  of  the  heart  muscle  or  its  lining  membrane  is  normal. 

Symptoms  and  Diagnosis. — According  to  Broadbent,  there  is  a  con- 
traction seen  behind  in  the  infrascapular  region,  sometimes  on  the  left, 
sometimes  on  the  right,  side  in  the  region  of  the  eleventh  or  twelfth  rib. 
Anteriorly  we  have  the  characteristic  sign.  It  is  a  systolic  retraction 
of  the  chest  at  or  near  the  apex  of  the  heart,  sometimes  at  the  tip  of  the 
sternum.  This  is  due  to  the  external  pericardial  adhesions,  and  is  often 
better  made  out  by  palpation  than  by  inspection.  After  the  systole  there 
is  a  rapid  rebound,  known  as  the  diastolic  shock.  A  collapse  of  the  cervical 
veins  during  the  diastole  of  the  heart,  known  as  Friedreich's  sign,  is  also 
seen.  Sometimes  we  see  an  inspiratory  swelling  (Kussmaul).  In  addition, 
the  pulsus  paradoxus  is  significant  of  the  presence  of  pericardial  adhesions, 
or  rather  of  the  dilatation  that  succeeds  the  adhesions.  The  pulse  is  small 
and  feeble  during  inspiration,  assuming  greater  strength  during  the  period 
of  expiration. 

Percussion  shows  an  increase  in  the  cardiac  dullness  in  all  directions. 
The  position  of  the  apex  and  the  percussion  outline  of  the  heart  do  not 
change  with  the  posture  of  the  patient,  and  the  cardiac  dullness  is  but 
little  affected  by  full  inspiration.  A  systolic  murmur  is  often  present. 
The  diagnosis  of  adherent  pericardium  always  presents  difficulties,  but  it 
can  be  made  with  tolerable  certainty  in  a  considerable  portion  of  the  cases. 
On  account  of  the  enlargement  of  the  heart  and  the  frequency  of  murmurs, 
it  is  usually  mistaken  for  valvular  disease.  The  lesion  is  a  permanent  one 
and  tends  to  increase.  If  a  child  suffers  with  valvulitis  and  the  symptoms 
do  not  yield  to  digitalis,  then  adhesive  pericarditis  should  he  suspected. 

Treatment. — There  is  no  known  method  of  treatment  which  will  mod- 
ify or  improve  this  condition,  excepting  a  supporting  diet  with  absolute 
rest  in  bed  and  general  restorative  treatment.  It  is  very  important  to 
watch  the  emunctories  and  stimulate  them  if  their  action  is  sluggish. 

Tuberculosis  of  the  Pericardium. 

This  condition  is  rarely  met  with  as  a  primary  process;  it  is  chiefly  met 
with  as  a  secondary  process.  It  usually  partakes  of  a  general  tuberculous 
process  in  which  aU  the  organs  of  the  body  participate,  among  them  the 
pericardium. 


MYOCARDITIS.  343 

Diagnosis. — Tlie  diagnosis  of  this  condition  depends  on  the  symptoms 
which  usually  accompany  pericarditis.  The  tubercular  nature  of  the  dis- 
ease must  depend  on  the  presence  of  tubercle  bacilli  in  the  exudation, 
although  linger  denies  the  possibility  of  making  such  a  diagnosis.  Most 
probably  a  positive  diagnosis  will  be  made — as  in  many  obscure  lesions — 
post  mortem. 

The  treatment  is  the  same  as  that  previously  described  in  the  article 
on  "Acute  Pericarditis." 

Hydropericaedium. 

Occasionally  we  meet  with  cases  in  which  the  symptoms  of  dyspnoea 
and  cyanosis  rapidly  develop.  Steffen  maintains  that  such  alarming  symp- 
toms frequently  occur  within  a  few  hours,  and  that  the  same  will  some- 
times disappear  under  appropriate  treatment  in  a  few  days. 

Patholo^. — -A  transudation  of  serous  liquid  in  the  pericardium  with- 
out inflammatory  process  is  usually  a  secondary  condition  in  which  drop- 
sical effusions  appear.  Usually  hydrsemic  conditions  of  the  blood,  such  as 
the  result  of  long-continued  fevers  in  infectious  diseases,  tuberculosis  among 
others,  predispose  to  this  condition. 

The  prognosis  depends  upon  the  cause  leading  to  this  condition. 

The  treatment  is  chiefly  restorative,  and  will  depend  on  maintaining 
the  strength  of  the  child  by  careful  diet  and  hygiene. 

Myocarditis. 

An  inflammatory  condition  involving  the  heart  muscles;  may  be  either 
acute  or  chronic.  It  occurs  as  {a)  parenchymatous,  (&)  interstitial. 
Steffen  has  reported  33  cases.  It  is  met  with  more  often  in  boys  than  in 
girls. 

This  affection  is  very  frequently  seen  during  the  convalescence  of  diph- 
theria. It  is  also  a  frequent  complication  of  scarlet  fever.  I  have  met  this 
complication  in  the  wards  of  the  Willard  Parker  and  Eiverside  Hospitals. 

Causes. — When  it  is  primary  it  is  due  either  to  rheumatism,  congenital 
syphilis,  or  tuberculosis.  Secondary,  it  is  due  to  endocarditis,  pericarditis, 
toxins  from  infectious  fevers,  or  phosphoric,  arsenic,  or  lead  poisoning. 
Traumatism  has  also  caused  myocarditis. 

Pathology. — The  heart  muscles  appear  pale,  soft,  and  friable.  The 
whole  heart  is  not  always  affected;  certain  portions  may  show  evidences  of 
degeneration  and  fatty  infiltration,  while  another  portion  may  be  normal. 
The  myocardium  is  very  susceptible  to  the  toxins  of  infectious  diseases. 
This  is  especially  true  ivlien  diphtheria  and  scarlet  fever  have  existed  prioi' 
to  the  heart  lesions. 

Symptoms. — There  are  two  positive  signs  of  myocarditis,  arrhythmia 
and  bradycardia.    The  pulse  is  very  feeble  and  slow,  in  some  cases  irregular. 


344  DISEASES  OF  THE  HEART. 

Sometimes  the  pulse  rate  is  increased.  The  extremities  are  usually  xjold.  In 
some  cases  there  is  a  slight  rise  of  temperature,  100°  to  101°  F.  Other  cases 
show  a  subnormal  rectal  temperature  of  96°  to  98°  P.  It  is  very  evident  that 
the  toxins  of  the  infectious  diseases  inhibit  the  proper  action  of  the  thermic 
centers.  I  have  seen  distinct  vasomotor  disturbances,  such  as  unilateral 
flushing,  affecting  one  cheek  or  the  lobe  of  one  ear.  The  child  shows  a 
marked  general  depression.  There  is  a  general  devitalization  noticeable ;  also 
marked  apathy.    The  child  appears  listless  and  prefers  to  rest. 

The  Heart. — There  is  an  irregular,  very  rapid  heart  action.  The 
heart  sounds  are  very  indistinct.  When  the  above  symptoiQs  occur  during 
the  course  of  infectious  diseases,  myocarditis  should  be  suspected.  Some- 
times there  is  faintness,  severe  dyspnoea,  and  cyanosis.  ISTot  infrequently 
there  is  albumin  in  the  urine.  Dilatation  and  hypertrophy  sometimes  occur 
without  showing  distinct  symptoms.  The  ratio  of  the  pulse  and  respiration 
will  be  disarranged. 

Diagnosis. — In  some  cases  this  is  very  difficult  to  make.  The  presence 
of  a  slow  pulse  and  muffled  heart  sounds  during  the  beginning  or  during  the 
convalescence  of  acute  infectious  diseases  should  always  lead  to  the  sus- 
picion of  myocarditis.  A  slow  pulse  in  itself  should  always  be  looked  upon 
as  ominous. 

Frequently  a  diagnosis  of  myocarditis  is  made  at  the  autopsy  when 
no  positive  symptoms  of  the  condition  were  p'esent  during  life. 

Prognosis. — The  prognosis  is  certainly  not  good.  Earely  do  we  find 
cases  of  myocarditis  recover.  This  is  especially  true  when  myocarditis  com- 
plicates the  acute  infectious  diseases  and  the  child  is  in  a  devitalized 
condition. 

Treatment. — Excitement  or  exertion  may  cause  sudden  death.  The 
child  requires  absolute  rest.  It  should  be  put  to  bed  in  a  recumbent  posi- 
tion. High  saline  injections  at  a  temperature  of  115°  to  120°  F.,  using 
several  quarts  of  salt  water,  can  be  tried  two  or  three  times  a  day.  The 
diffusible  effect  of  the  hot  saline,  and  consequently  the  tendency  to  eliminate 
toxins  through  the  kidney,  should  serve  as  a  valuable  therapeutic  adjim.ct. 
Life  can  certainly  be  prolonged  by  this  measure;  if  it  is  cautiously  done, 
so  as  not  to  exert  the  child's  heart,  the  result  will  be  apparent  very  soon. 

Another  diffusible  stimulant  which  has  served  me  very  well  is  the 
injection  of  hot  water  to  which  several  grains  of  carbonate  of  ammonia 
have  been  added.  In  some  cases  of  severe  cardiac  depression  I  have  seen 
good  results  from  the  injection  of: — ■ 

IJ  Sp.  ammon.  aromatic i^  drachm 

Hot  water 1    quart 

Inject  through  a  rectal  tube  into  the  colon,  at  a  temperature  of  110°  to  115°  F., 
once  in  six  hours,  alternating  with  the  hot  saline. 


MYOCARDITIS.  345 

In  syphilis  or  tuberculous  conditions  the  treatment  should  be  specific. 
When  evidences  of  heart-failure  exist,  strychnine,  caffein,  whisky,  aromatic 
spirits  of  ammonia,  and  nitroglycerine  may  be  used.  Spartein  in  small 
doses  (Vio  ^ain  every  hour)  may  be  given.  The  value  of  concentrated 
food  is  greater  in  this  condition  than  in  any  other. 

Feeding. — No  drug  will  give  as  much  strength  to  the  body  as  food. 
Food  should  be  given  very  frequently  in  small  quantities.  A  cup  of  con- 
centrated chicken  broth  or  beef  broth  should  be  given,  and  two  hours  later 
the  white  of  two  or  three  raw  eggs  with  sweetened  coffee.  Milk  punch, 
cocoa,  chocolate,  or  strained  oatmeal  gruel  may  be  given.  One  of  the  above 
foods  may  be  given  every  two  hours.  Several  ounces  may  be  given  at  each 
feeding.  The  outcome  of  the  case  depends  upon  strengthening  the  heart. 
My  plan  has  been  to  give  the  strychnine  in  the  food.  Drugs  have  a  more 
diffusible  effect  and  seem  to  enter  the  circulation  better  when  combined 
with  hot  food.  If  for  any  reason  the  stomach  is  sensitive  and  does  not 
retain  food,  rectal  feeding  with  peptonized  milk  may  be  necessary  along 
with  the  hot  salines  previously  mentioned. 


CHAPTER  III. 

DISEASES   OF  THE  LIVER. 

The  Liver. 

The  liver  in  nurslings  is  relatively  larger  than  in  adults.  To  examine 
the  liver  place  the  child  on  its  back  with  the  legs  slightly  flexed  toward  the 
abdomen.    Have  the  child,  if  possible,  breathe  with  regularity. 

Position  of  Liver. — Dullness  can  be  made  out  from  the  fifth  inter- 
costal space  in  the  mammary  line  to  about  one  inch  below  the  border  of 
the  ribs.  In  the  axillary  line  it  reaches  from  the  seventh  intercostal,  and 
posteriorly  a  dullness  is  made  out  at  the  ninth  intercostal  space.  It  extends 
downward  and  can  best  be  made  out  by  palpating. 

Birch-Hirschfeld  found  the  average  weight  of  the  liver  in  the  new- 
born infant  about  four  and  one-half  ounces  (127  grams). 

Steflen,  who  has  devoted  considerable  attention  to  the  liver,  states  that 
the  left  lobe  is  relatively  larger  in  the  child  than  in  the  adult. 

Bile. 

The  quantity  of  bile  in  the  gall-bladder  is  very  small.  It  is  of  a  golden- 
yellow  color,  and  has  a  neutral  reaction.  Its  specific  gravity  varies  from 
1014  to  1053.  According  to  Baginsky,  the  bile  in  nurslings  contains  or- 
ganic salts — cholesterin  and  lecithin — fat,  and  various  acids  in  less  pro- 
portion than  in  adults.  Baginsky  was  able  to  demonstrate  the  presence 
of  glycocholic  acid.  The  presence  of  a  much  less  quantity  of  bile-acids  in 
the  infant  is  a  beneficial  physiological  condition.  It  is  a  well-known  fact 
that  these  acids  inhibit  the  digestive  action  of  the  pepsin  and  of  the  pan- 
creatic juice.  Another  point  is  that  the  absence  of  a  bile-acid  prevents  the 
assimilation  of  large  quantities  of  fat,  as  it  is  impossible  to  split  up  the 
fat  into  fatty  acid  and  glycerine.  Thus,  fermentative  processes  are  much 
more  frequent  in  nurslings  and  appear  with  greater  intensity  than  in  the 
adult,  because  of  the  biliary  acids.  The  amylacea  and  all  substances  con- 
taining flour  are — owing  to  the  above-described  condition  of  the  pancreatic 
juice  and  the  bile — not  fit  substances  to  give  the  infant,  especially  during 
its  first  three  months  of  life,  although  very  small  quantities  can  he  digested, 
and  after  the  fourth  month  are  not  only  digested,  but  also  absorbed. 

Baginsky  and  Sommerfeld  found  large  quantities  of  mucin  in  the 
bile. 

Jaundice   (Icterus).^ 

There  are  two  forms  of  jaundice  met  with  in  children :  first,  hepato- 
genic ;  second,  hgematogenic.     The  most  common   form   seen   in   children 


^Icterus  neonatorum  is  described  in  Part  II,  "Diseases  of  the  New  13orn," 
(346) 


ABSCESS  OF  THE  LIVER.  347 

is  a  catarrhal  jaundice.  This  is  due  to  an  extension  of  the  catarrhal  process 
from  the  stomach  to  the  duodenum,  causing  catarrh  of  the  bile  ducts.  (See 
article  on  "Gastroduodenitis.'^)  In  the  hepatogenic  form  there  is  an  ob- 
struction to  the  flow  of  bile  into  the  bowel.  It  is  also  called  obstructive 
jaundice. 

In  the  hasmatogenic  form  there  is  no  obstruction  to  the  flow  of  bile, 
but  the  jaundice  is  due  to  blood  conditions.  We  find  jaundice  in  sepsis, 
in  malaria,  and  in  typhoidal  conditions.  Mechanical  obstructions,  such  as 
round  worms  entering  the  common  duct,  have  been  reported,  but  they  are 
rarities. 

Acute  Congestion  of  the  Liver. 

In  literature  very  little  light  is  shed  on  this  condition.  Some  authors 
state  that  malaria  and  other  poisons,  particularly  phosphorus,  may  cause 
this  condition.  I  believe  that  acute  congestion  of  the  liver  is  frequently 
associated  with  acute  gastric  catarrh.  It  is  also,  no  doubt,  one  of  the  factors 
on  which  intestinal  indigestion  hinges.  The  symptoms  are  mainly  those 
of  enlargement  which  can  be  made  out  by  palpation  and  functional  de- 
rangement such  as  will  be  considered  in  the  next  article. 

Abscess  of  the  Liver. 

While  the  condition  is  rare  in  children,  Legrand  found  102  cases 
reported : — 

Dysenteric   abscesses '. 31 

Traumatic   abscesses    19 

Appendicitis   abscesses    15 

Typhoid  abscesses 6 

Tuberculous  abscesses    10 

Worms    13 

Pyemia    2 

Doubtful 6 

In  the  chapter  on  the  intestinal  tract  I  have  referred  to  worms  as  a 
causative  factor.  Ascarides  have  been  found  in  the  bile  duct  and  the 
hepatic  duct  associated  with  multiple  abscesses.  They  have  also  been  found 
in  the  pancreatic  duct. 

The  symptoms  of  fever,  pain,  and  swelling  in  the  region  of  the  liver 
are  very  marked.    Aspiration  will  aid  in  making  the  diagnosis. 

The  prognosis  depends  on  the  early  recognition  of  the  abscess  and  its 
inmiediate  relief  by  free  incision. 

Treatment. — An  exploratory  puncture  should  be  made  early  in  the  dis- 
ease, and,  as  soon  as  pus  is  located,  free  incision  should  be  made. 


348  DISEASES  OF  THE  LIVER. 

Gall-stones  (  Cholblithl4.sis)  . 

Authentic  cases  of  gall-stones  in  childhood  are  rare.  The  symptoms  of 
biliary  colic  with  jaundice,  pain,  and  fever  are  identical  with  the  adult  type 
of  the  disease.  The  diagnosis  can  be  made  by  the  aid  of  an  x-ray  examina- 
tion. No  operation  should  be  performed  until  a  radiogram  strengthens  the 
diagnosis. 

Functional  Disorders  of  the  Liver. 

Functional  Derangement. — This  very  common  condition  is  character- 
ized by  either  a  total  absence  or  a  diminution  in  the  quantity  of  bile  secreted. 
This  functional  disorder  usually  causes  very  dry,  grayish  or  whitish,  "clay- 
colored"  stools;  also  flatulence.  The  urine  is  of  a  very  dark  reddish  or 
brownish  color.  Frequently  the  skin  and  conjunctival  mucous  membrane 
are  pigmented.  The  temperature  may  reach  101°  F. ;  rarely  higher  than 
103°  F.  If  after  rest,  proper  diet,  and  hepatic  stimulation  the  fever  per- 
sists, then  the  possibility  of  abscess  in  the  gall-bladder  should  be 
remembered. 

Treatment. — Calomel,  podophyllin,  or  elaterin  in  small  doses.  The 
salines  and  phosphate  of  soda  in  5-  or  10-  grain  doses  can  be  given.  Diluted 
hydrochloric  acid  or  diluted  nitromuriatic  acid,  in  1-drop  doses,  is  a  good 
bile  stimulant.  In  some  cases  a  gentle  faradic  current  and  massage  may 
do  good.  A  cold  spray  over  the  liver  will  also  tone  the  same.  Large  quan- 
tities of  liquids  will  sometimes  aid  in  relieving  functional  disturbance  of 
the  liver. 

Displacement  of  the  Liver. 

The  liver  may  be  displaced  downward  when  the  ribs  are  contracted  in 
size.  This  condition  is  best  noted  in  rickets.  The  liver  may  also  be  dis- 
placed by  pleural  effusions.  It  is  found  much  lower  in  diseases  wherein 
emaciation  takes  place,  such  as  in  marasmic  or  tubercular  manifestations. 
In  these  latter  conditions  relaxation  of  the  abdominal  walls  permits  the 
liver  to  occupy  a  position  much  lower  than  normal. 

Displacement  Due  to  Diseases  of  the  Adjacent  Organs. — The  liver  is 
sometimes  displaced  by  tumors  arising  in  the  right  pelvic  region,  chiefly 
from  swelling  associated  with  the  right  kidney.  In  a  case  of  mine  (see 
chapter  on  "Pyelitis")  the  kidney  pushed  the  liver,  upward  and  to  the  left. 
The  liver  returned  to  its  normal  position  after  the  diseased  kidney  was 
removed. 

Several  years  ago,  at  the  Kaiser  and  Kaiserin  Friedrich  Children's  Hospital  of 
Berlin,  I  saw  a  case  of  a  child  having  a  supposed  tumor  involving  the  liver.  While 
all  believed  that  the  swelling  was  associated  with  the  liver,  after  the  abdomen  was 
opened  it  was  found  that  the  kidney  was  the  seat  of  the  trouble  and  that  the  liver 
was  unaffected. 


AMYLOID  DEGENERATION.  349 


Descended  Liver. 

Eowland  Gr.  Freeman,  in  studying  a  series  of  496  autopsies  in  children, 
states  that  he  has  met,  not  very  rarely,  with  descended  liver.  These  en- 
laiged  livers  were  found  in  children  suffering  with  tuberculosis  and  lobar 
pneumonia.  In  his  cases  the  liver  had  slipped  down  the  right  side  of  the 
abdomen. 

Amyloid  Degeneration  (Waxy  Liver). 

This  is  an  extremely  rare  condition.  Freeman  mentions  but  two  cases 
in  his  large  post-mortem  experience,  one  case  associated  with  tuberculous 
disease  of  the  vertebrse  and  psoas  abscess,  and  the  other  case  in  a  child 
suffering  from  progressive  ansemia.  The  liver  and  kidney  were  waxy  in 
both  cases. 

Experimentally,  amyloid  degeneration  has  been  produced  by  the  action 
of  the  toxins  of  the  staphylococcus  pyogenes  aureus. 

Symptoms. — Special  symptoms  which  could  be  called  those  specifically 
due  to  this  condition  cannot  be  described.  The  symptoms  of  the  disease 
associated  with  amyloid  degeneration,  are  present  on  palpation.  The  liver  is 
enlarged,  the  surface  very  smooth  and  hard,  without  tenderness.  The 
spleen  is  also  enlarged.  Dropsy  is  usually  present.  The  latter  symptom 
must  not  necessarily  be  due  to  the  kidney,  but  may  result  from  pressure 
of  the  swollen  liver  upon  the  vena  cava.  When  this  disease  is  associated 
with  syphilis,  then  symptoms  of  the  latter  disease  may  also  be  found. 

The  prognosis  is  usually  bad. 

Treatment. — This  depends  on  the  symptoms,  which  require  urgent 
management.  Syphilis,  when  present,  requires  anti-syphilitic  treatment. 
The  outcome  of  the  case  depends  on  restorative  treatment,  including 
nutrition. 

Fatty  Liver. 

Fatty  degeneration  of  the  liver  is  very  frequently  noted  in  children. 
Wollstein  has  found  201  cases  of  fatty  liver  in  345  consecutive  autopsies. 
Freeman  and  Long  studied  a  series  of  296  autopsies  at  the  Foundling  Hos- 
pital, and  found  202,  or  about  68  per  cent.,  fatty  livers.  This  disease  is 
not  as  frequently  found  associated  with  wasting  diseases  as  is  claimed. 

The  following  classification  of  causes  or  conditions  with  which  fatty 
liver  is  associated  is  given  by  C.  Oddo,  in  Gmnclier's  Maladie  de  I'Enfance: — 

1.  Intoxications:    Phosphorus,  alcohol. 

2.  (a)  Infections,  acute:  typhoid  fever,  measles,  scarlet  fever,  small- 
pox and  diphtheria,  bronchopneumonia,  acute  general  tuberculosis,  and 
diarrhoea.  (&)  Infections,  chronic:  chronic  tuberculosis,  hereditary 
syphilis. 


350  DISEASES  OF  THE  LIVER.   - 

3.  Maladies  of  nutrition :   chronic  gastroenteritis,  rachitis. 

4.  Fatty  liver  associated  with  the  hepatic  lesions. 

Cirrhosis  of  the  Liver  (Interstitial  Hepatitis). 

Two  varieties  of  cirrhotic  liver  are  seen  in  children ;  they  are :  (a) 
atrophic,  (&)  hypertrophic.  This  condition  is  caused  by  the  same  factors 
that  produce  cirrhosis  in  the  adult.  The  two  most  impoitant  factors  that 
produce  this  condition  are  syphilis  and  the  excessive  use  of  alcohol.  Freeman 
reports  two  cases  in  neither  of  which  alcohol  was  the  cause  of  the  con- 
dition, nor  was  any  acute  disease  reported  prior  to  the  cirrhosis. 

Symptoms. — ^Digestive  disturbances,  such  as  fullness  in  the  abdomen, 
constipation,  or  diarrhoea,  exist.  The  temperature  is  irregular.  As  a  rule, 
the  liver  is  not  enlarged. 

Diagnosis. — This  is  sometimes  extremely  difficult  and  can  only  be 
determined  positively  by  a  post-mortem. 

Prognosis. — ^The  prognosis  depends  on  the  cause.  If  due  to  syphilis, 
the  prognosis  is  fair ;  if  due  to  alcohol,  then  it  is  grave. 

Treatment. — ^The  treatment  of  the  case  depends  on  the  symptoms 
presented. 

Focal  Necrosis. 

This  is  usually  found  associated  with  infectious  diseases.  It  has  been 
observed  resulting  from  the  toxin  of  diphtheria  and  measles.  Freeman 
found  focal  necrosis  in  4  cases  out  of  14  consecutive  autopsies  on  measles 
cases. 

Summary. — "1.  Descent  of  the  liver  down  the  right  side  of  the  abdo- 
men, so  that  the  right  lobe  reaches  below  the  crest  of  the  ilium,  occurs  oc- 
casionally in  infants,  and  particularly  in  those  in  whom  the  liver  is 
enlarged. 

"2.  Fatty  livers  occur  very  frequently  in  the  infants  and  children 
who  die  at  the  New  York  Foundling  Hospital,  or  in  about  41  per  cent, 
of  all  cases. 

"3.  The  condition  of  nutrition  of  the  child,  as  expressed  by  the  absence 
of  fat  in  general  and  wasting  of  tissue,  apparently  has  no  connection  with 
the  fatty  condition  of .  the  liver,  the  condition  of  nutrition  in  the  cases 
having  fatty  livers  averaging  about  the  same  as  in  the  whole  number  of 
cases. 

"4.  Fatty  livers  occur  rarely  in  the  following  chronic  wasting  diseases : 
marasmus,  mahiutrition,  rachitis,  and  syphilis,  unless  such  condition  be 
complicated  by  an  acute  disease. 

"5.  With  tuberculosis  fatty  livers  occur  not  more  often  than  with  other 
conditions. 


SUBPHRENIC  ABSCESS.  351 

"6.  Fatty  livers  occur  most  often  with  the  acute  infectious  diseases  and 
gastro-intestinal  disorders. 

"7.  The  two  cases  of  cirrhosis  of  the  liver  examined  by  the  writer  ran 
a  comparatively  acute  course.  The  livers  on  section  showed  a  marked 
hyperplasia  of  the  so-called  new-formed  bile  ducts. 

"8,  Focal  necrosis  of  the  liver  may  be  a  lesion  of  measles." 

Read  article  on  "Congenital  Obliteration  of  the  Bile  Ducts"  in  the  sec- 
tion on  'The  New-born  Baby." 

Subphrenic  Abscess. 

This  condition  is  very  rare  in  children.  It  consists  of  an  accumulation 
of  pus  above  the  liver,  hut  beneath  the  diaphragm.  Carl  Beck  has  described 
this  condition  in  extenso  in  a  paper  read  before  the  New  York  Academy  of 
Medicine  several  years  ago. 

Meltzer^  reports  a  case  occurring  in  a  child  2  years  old. 

Jopson^  has  recently  reported  a  case  from  the  Children's  Hospital, 
in  Philadelphia. 

MaydP  has  studied  a  series  of  179  cases.  Of  these  cases,  which  were 
found  in  all  ages,  10,  or  5.9  per  cent.,  were  under  15  years  of  age.  The 
causes  in  Maydl's  cases  were  attributed  to  the  stomach  and  duodenum, 
intestinal,  pericgecal  (including  appendicitis),  echinococcus,  subcutaneous 
traumatism,  cholangitis,  perinephritis,  metastatic  wounds  and  gunshot  in- 
juries, and  caries  of  the  ribs. 

Jopson,  in  reporting  the  causes  of  12  of  his  cases,  includes  appendi- 
citis, perforated  gastric  or  duodenal  ulcer,  caries  of  the  dorsal  vertebrae, 
traumatism,  and  calculous  cholecystitis. 

In  a  case  reported  by  A.  Frederici*  a  girl,  8  years  old,  had  an  abscess 
which  ruptured  into  the  lung.  The  diagnosis  of  subphrenic  abscess,  second- 
ary to  liver  abscess,  was  founded  on  tenderness  over  the  liver  region  before 
the  abscess  ruptured,  and  on  the  absence  of  air  in  the  abscess  cavity. 

Baginsky  reported  a  case  in  a  child,  2%  years  old,  secondary  to 
appendicitis. 


*New  York  Medical  Journal,  June  24,  1893. 
^Archives  of  Pediatrics,  February,  1904. 
"  "Subphrenic  Abscess,"  Wien,  1894. 
*  In  Monatschr.  f .  Kinderheilk.,  July,  1903. 


CHAPTBE  IV. 

DISEASES  OF  THE  SPLEEN  AND  PANCREAS. 

The  Spleen. 

One  of  the  most  difficult  organs  of  a  child  to  examine  is  the  spleen. 
It  can  be  palpated  between  the  ninth  and  eleventh  ribs.  It  is  impossible 
to  positively  outline  the  spleen  by  percussion.  For  the  purpose  of  examina- 
tion the  child  should  be  placed  flat  on  its  back  with  the  thighs  flexed.  By 
gentle  manipulation  with  the  tips  of  the  fingers,  we  can  frequently  in  a 
quiet  child  press  under  the  free  border  of  the  ribs  and  feel  the  smooth  border 
of  the  spleen.  Some  authors  maintain  that  when  the  spleen  is  palpable 
it  is  enlarged.  I  have  frequently  been  able  to  j^alpate  the  spleen  in  per- 
fectly normal  infants. 

There  are  no  primary  diseases  of  the  spleen,  although  it  is  frequently 
the  seat  of  tubercular  disease. 

Enlargement  of  the  Spleen  (Splenitis). 

An  enlarged  spleen  is  frequently  seen  in  various  systemic  conditions. 
It  is  one  of  the  characteristic  symptoms  of  many  of  the  acute  infectious 
diseases.  It  is  a  prominent  symptom  of  malarial  infection  and  typhoid 
fever,  and  next  to  the  condition  of  the  blood  itself  is  a  very  valuable  aid 
in  the  diagnosis.  In  cachectic  conditions  and  in  such  constitutional  dis- 
orders affecting  the  blood,  as,  for  example,  in  rickets,  a  very  large  spleen 
can  frequently  be  palpated.  An  enlargement  of  the  spleen  reaching  into 
the  groin  was  seen  by  me  in  a  case  of  rickets.  The  spleen,  therefore,  is  a 
very  valuable  aid  to  diagnosis  in  many  conditions.  For  a  description  of 
the  method  of  examination  see  article  on  the  "Spleen  in  the  New-born 
Baby." 

Wandering  Spleen  (Movable  Spleen,  Lien  Mobilis). 

When  there  is  an  elongation  of  the  gastro-lienal  ligament,  the  spleen 
can  be  readily  moved. 

Causes. — Severe  paroxysms  of  coughing,  such  as  whooping-cough  or 
traumatism,  can  cause  this  condition. 

Symptoms. — In  young  children  there  are  no  special  guides.  Older 
children  complain  of  pain  on  the  left  side  and  vague  abdominal  pains. 
(352) 


THE   PAN  CUE  AS.  353 

Diagnosis. — The  diagnosis  is  made  Ijy  pal})ating  tlie  wandering  spleen. 

Treatment. — An  abdominal  bandage  to  support  tiie  abdomen  will  fre- 
quently aid  in  replacing  the  spleen.  Rarely  will  surgical  treatment  be 
demanded. 

The  Pancreas. 

The  pancreas  is  situated  beliind  the  stomach.  It  is  about  the  height 
of  the  first  lumbar  vertebra.  The  function  of  the  pancreas  is  known  as 
tlie  amylolytic  function,  namely,  starch  digestion,  in  reality  the  conversion 
of  starch  into  sugar. 

Diseases  of  the  Pancreas. 

Syphilitic  tissue  changes  are  frequently  seen  in  the  pancreas.  Malig- 
nant tumors  are  occasionally  reported  in  the  literature.  V7hen  such  lesions 
exist  they  tax  the  diagnostic  skill  of  the  specialist.  The  diagnosis  is  rarely 
made  inira  vitam. 


CHAPTEE  V. 
DISEASES  OF  THE  PEEITONEUM. 

Acute  Peritonitis. 

This  is  a  very  rare  condition  in  childliood.  It  is  most  frequently 
seen  in  practice  in  the  new-bom,  where  the  inflammation  is  the  result  of 
a  pyogenic  infection  through  the  lunbilical  vessels.  This  has  been  de- 
scribed in  the  section  on  the  "New-born  Baby." 

Etiology.^-This  inflammation  is  frequently  the  result  of  tramnatism. 
It  may  follow  the  operation  for  appendicitis  or  other  operation  on  the 
abdomen.  Cases  have  been  reported  where  an  infection  such  as  gonor^ 
rhoea  or  vulvovaginitis  has  extended  into  the  uterus  or  into  the  perito- 
neum. This  condition  may  frequently  accompany  Pott's  disease  or  peri- 
nephiitis,  and  may  also  follow  deep-seated  bums  in  which  cellulitis  or 
erysipelatous  inflammation  exists. 

I  have  seen  peritonitis  as  a  complication  of  scarlet  fever  in  hospital 
and  private  practice. 

Bacteriology. — ^The  streptococcus  is  most  frequently  found  to  be  the 
cause  of  peritonitis  in  the  new-bom.  Sometimes  the  pneumococcus  and 
the  bacterium  coli  commune  are  found. 

Pathology. — Serous  Form:  There  is  a  large  outpouring  of  serum 
which  is  clear,  and  there  is  a  small  amount  of  lymph  associated  with  it. 
When  recovery  takes  place  the  serum  is  absorbed.  Adhesions  usually 
follow. 

Fibrinous  Form. — The  peritoneum  is  intensely  congested,  the  blood- 
vessels injected,  and  a  large  amount  of  lymph  is  throvm  out  with  very  little 
serum.  The  pathological  process  corresponds  to  that  condition  seen  in 
flbrinous  pleurisy.  Firm  adhesions  resulting  in  the  formation  of  connect- 
ive-tissue bands  usually  remain. 

Purulent  Form. — A  large  amount  of  Ijmph  and  pus  are  present  with 
the  usual  evidences  of  inflammation.  The  abscess  is  rarely  localized  or 
isolated  from  the  rest  of  the  peritoneum  by  a  thick  wall  of  fibrin.  Spon- 
taneous evacuation  of  pus.  through  the  vagina,  rectum,  bladder,  or  um- 
bilicus has  been  reported.  Such  cases  may  recover.  As  a  rule,  purulent 
peritonitis  is  fatal. 

Symptoms. — The  sjTQptoms  of  fever,  vomiting  with  pain,  and  uniform 

distention  of  the  abdomen  are  usually  present.    There  is  also  tympanites, 

and  when  liquid  is  present  fluctuation  can  be  felt.     The  child  is  usually 

found  flat  on  its  back  with  the  legs  flexed.    Diarrhoea  exists  in  some  cases, 

(354) 


CHRONIC  PERITONITIS.  355 

constipation  in  others.    Tlie  child  appears  very  sick  and  suffers  continuous 
pain.    The  following  case  occurred  in  my  practice: — 

Jessie  M.,  2  years  old,  had  typical  symptoms  of  influenza.  There  wore  coryza, 
sneezing,  and  a  temperature  of  104°  F.  At  tliis  time  there  had  been  a  house 
epidemic,  and  all  members  of  the  family  were  sull'ering  with  influenza.  The  child 
had  anorexia  and  vomiting,  and  cried  continuously  as  if  in  pain.  The  abdomen  was 
distended,  and  constipation  reported.  A  soap-water  enema  was  ordered,  and, 
although  a  good  result  followed,  the  crying  continued.  The  abdomen  was  tympanitic 
on  percussion  and  the  uniform  distention  continued.  An  ice-bag  was  ordered,  but 
gave  no  relief.  Local  applications  of  warm  antiphlogi^iine  poultices  seemed  to  afl"ord 
relief.  Chamomile  injections  at  a  temperature  of  115°  F.  were  ordered  given  into  the 
colon.  When  the  same  passed  off  another  injection  of  8  ounces  of  warm  olive-oil 
not  only  relieved  the  child,  but  produced  sleep.  These  injections  were  repeated  three 
times  a  day.  Codeine  with  calcined  magnesia  was  ordered  to  relieve  pain  and  for 
the  antifermentative  effect. 

Feeding. — Whey  was  given  every  four  hours  and  several  teaspoonfuls  of 
Mulford's  predigested  beef  with  whisky  every  two  hours.  The  disease  lasted  about 
two  weeks.     The  child  recovered. 

Prognosis. — This  disease  is  frequently  fatal,  especially  the  purulent 
variety.  The  most  favorable  cases  are  those  in  which  there  is  a  sero- 
fibrinous exudation.  The  outcome  depends  on  the  vitality  at  the  time  of 
illness. 

Treatment. — Warm  applications  have  served  me  best,  although  some 
autJiors,  tspetially  the  Germans,  prefer  ice.  Hot,  moist  flannels  to  which 
15  to  30  drops  of  turpentine  have  been  added  will  usually  relieve  tym- 
panites. Codeine  should  be  given  until  the  child  is  comfortable,  Vio 
to  ^/s  grain,  every  two  hours  or  oftener.  My  results  have  been  best  when 
milk  was  omitted.  Soup  or  broth  may  be  given.  Whey  is  valuable  in  this 
condition ;  also  white  of  raw  egg  well  beaten  with  sweetened  water.  The 
treatment  described  in  the  clinical  case  above  cited  is  my  usual  method 
adopted.  The  high  colon  flushings  are  cleansing  and  soothing.  When 
great  prostration  exists,  instead  of  using  chamomile  tea  and  warm  olive-oil, 
normal  saline  solution  has  a  more  toning  effect.  Special  symptoms,  such 
as  collapse,  require  strychnine,  nitro-glycerine,  or  caffeine  sodium  benzoate. 
Also  liberal  stimulation  with  champagne  or  whisky.  Oxygen  if  cyanosis 
exists. 

Operative  Treatment. — If  symptoms  of  appendicitis  exist,  then  an 
operation  may  do  good.  If  a  sudden  collapse  is  noted  perforation  should 
be  suspected  and  the  surgeon  consulted  at  once. 

ChKONIC    PERITOISriTIS     (iSTON-TUBERCULOUS). 

I\rany  authors  doubt  the  existence  of  a  non-tuberculous  peritonitis. 
Henoch  l^elieves  that  we  have  a  distinct  variety  of  chronic  peritonitis  which 
bears  no  relation  to  tuberoulosis. 


356  DISEASES  OF  THE  PERITONEUM. 

Symptoms. — In  a  distended  abdomen  associated  with  ascites  the  liquid 
can  be  made  out  by  palpation.  There  may  be  diarrhoea  or  there  may  be 
constipation.  DysiDeptic  symptoms  are  always  j^resent,  and  there  is  a 
slight  rise  of  temperature.  There  are  no  other  symptoms  of  tuberculosis, 
and  as  a  rule  no  other  com23lications  present,  xinsemia  is  usually  very 
marked. 

A  child  8  years  old  was  seen  by  me  during  my  service  in  the  German  Poliklinik. 
He  "was  a  bottle-fed  and  rachitic  boy.  He  had  suffered  tvith  a  very  severe  acute  milJc 
infection,  resulting  in  cholera  infantum  and  peritonitis.  The  child  developed 
symptoms  of  athrepsia  infantum.  Several  years  later  the  child  had  a  swollen,  tym- 
panitic abdomen  and  a  wave  of  fluid  could  be  made  out  by  careful  palpation.  I  aspi- 
rated about  1  pint  of  a  yellow  serous  fluid.  The  same  was  examined  and  no  tubercle 
bacilli  or  other  bacteria  were  found.  The  condition  improved.  The  case  was  seen 
by  me  twice  a  month,  and  it  was  necessary  to  tap  the  abdomen  each  time  to  relieve 
distention.  The  child  was  under  observation  about  six  years.  During  this  time 
large  doses  of  iodide  of  sodium,  codliver-oil,  and  iron  were  ordered.  A  change  to 
the  country  seemed  to  do  the  most  good.     The  child  is  well  to-day. 

TUBEECULOUS    PERITONITIS. 

The  peritoneum  frequently  participates  in  a  general  tuberculous  con- 
dition. It  may,  however,  be  an  entirely  independent  disease;  that  is,  it 
may  occur  as  the  primary  lesion  of  tuberculosis.  Biedert*  collected  a  series 
of  883  autopsies  on  tuberculous  children  of  various  ages.  He  found  the 
peritoneum  affected  in  18  per  cent.  The  disease  may  be  either  acute  or 
chronic. 

Pathology. — In  tubercular  peritonitis  the  lesions  are  those  of  a  general 
miliary  tuberculosis.  There  are  usually  not  very  many  tubercles  scattered 
through  the  peritoneum.  When  the  ascites  is  present  then  the  tubercles 
are  far  more  abundant.  The  omentum  and  mesentery  participate  in  the 
tuberculous  process.  The  liquid  present  may  be  brownish-colored  serum 
containing  blood ;  it  may  be  serous  or  yellowish  and  contain  pus. 

The  fibrous  form  usually  shows  adhesions  between  the  loops  of  intes- 
tine or  between  the  intestine  and  the  abdominal  wall.  In  the  ulcerative 
form  there  is  usually  a  fibrinous  exudation.  This  form  usually  follows  the 
miliary  or  fibrous  variety. 

Symptoms. — Well-marked  evidences  of  peritonitis  can  usually  be  made 
out  when  ascites  and  tympanites  are  present.  When  fever  is  associated 
with  it  in  addition  to  evidence  of  cough  or  other  physical  signs  in  the  lungs, 
then  the  diagnosis  is  not  doubtful.  Sometimes  the  tubercular  or  non- 
tubercular  forms  of  chronic  peritonitis  will  render  the  diagnosis  very  diffi- 
cult. 

Differential  Points. — Cirrhosis  of  the  liver  may  cause  an  ascites.  It 
is  rare  in  very  young  children.     If  the  history  of  syphilis  is  given  the 


'^  Jahrbuch  fiir  Kinderheilkunde,  xxi,  p.   178. 


TUBERCILOLS   I'KRlTON'mS. 


;r,7 


same  may  be  suspected.  In  some  cases  a  diagnosis  can  only  be  made  when 
an  exploratory  puncture  is  made  and  the  liuid  examined.  Even  then  the 
diagnosis  may  be  ditlicult.  The  only  method  then  left  is  to  make  a  micro- 
scopical examination  of  the  lihrous  nodules  or  rarely  by  inoculation  fxperi- 


Fig.    110. — Case  of  Tubercular  Peritonitis  Complicated  by  Tubercular 
Empyema.     Enlarged  Spleen.     Rachitic  Bottle-fed  Infant.      (Original.) 


ments.    The  following  cases  represent  tubercular  peritonitis  a?  occurring  in 
my  private  practice  : — 

M.  B.,  female,  2  years  old,  was  brought  to  me  with  a  history  of  cough,  dis- 
tended abdomen,  and  severe  constipation  alternating  with  diarrluva.  The  appetite 
was  poor,  and  the  child  had  lost  considerable  in  weight  and  has  not  been  well  since 
an  attack  of  measles  which  occurred  about  one  year  ago.  Evidences  of  tuberculosis 
were  made  out.  The  stool  contained  mucus.  Tubercle  bacilli  were  frequently  found 
in  the  mucous  discharges.  A  cavity  could  be  made  out  at  the  left  apex.  The  child 
suifered  with   recurring  pleurisy.     The   chest   contained   a   large  quantity  of   liquid 


358  DISEASES  OF  THE  PERITONEUM. 

effusion  for  over  four  months.  Kine  ounces  of  a  tliin,  greenish  fluid  was  aspirated 
from  the  left  side  of  the  thorax.  Examination  showed  tubercle  bacilli  and  also 
strei^tococci.  The  abdomen  was  enormously  distended,  and  a  wave  or  distinct  thrill 
of  liquid  could  be  felt  by  transmitted  palpation.  Extreme  dyspnoea  Avas  caused  by 
the  pressure  of  this  liquid  on  the  diaphragm.  By  aspiration  I  removed  1000  cubic 
centimeters  of  a  yellowish  serous  liquid  from  the  abdominal  cavity.  Temporary  relief 
was  afforded,  although  the  abdomen  refilled  very  rapidly.  It  was  necessary  to  tap 
the  same  once  every  six  weeks.  The  child  finally  died  of  exhaustion.  (See  Fig.  110.) 
A  second  case  occurred  in  a  little  girl,  Katie  B.,  about  9  years  old,  who  was 
under  the  treatment  of  Dr.  John  H.  Wurthman.  The  same  symptoms  as  I  have 
described  in  the  previous  case  were  found,  general  tuberculosis  with  especial  pul- 
monary manifestations  and  symptoms  »of  peritonitis.  In  this  case  I  aspirated  over 
three  pints  of  liquid  from  the  abdominal  cavity.  The  child  gradually  sank  and  died 
several  months  later. 

Prognosis. — When  ascites  is  present  the  prognosis  is  not  good,  espe- 
cially if  operative  measures  are  undertaken.     As  a  rule  cases  end  fatally. 

Treatment. — For  a  number  of  years  laparotomy  was  advised  as  the 
best  method  of  treating  tubercular  peritonitis.  Many  successful  cases  were 
reported.  It  was  believed  that  after  the  abdomen  was  opened,  drained,  and 
sunlight  admitted  this  latter  agent  aided  the  healing  process.  In  recent 
years  many  pediatricians  hold  the  opposite  view. 

Liglit  Treatment. — ISTot  very  long  ago  I  saw  a  case  of  tubercular  peri- 
tonitis (non-operative)  which  was  progressing  very  nicely.  It  was  under 
the  treatment  of  direct  sun  rays,  besides  receiving  an  electric  light  bath  for 
ten  minutes  each  day.  The  jnfluence  of  light  has  in  recent  years  demon- 
strated its  value,  especially  in  tubercular  manifestations. 

A  very  interesting  monograph  on  this  subject  has  been  published  by 
Aldibert,  of  Paris,  1893.  Baginsky  extols  the  value  of  operative  procedures 
in  tubercular  peritonitis.  The  reader  is  referred  to  modern  works  on  sur- 
gery for  exhaustive  data  on  this  subject. 

The  general  treatment  consists  in  restoratives,  building  up  the  body 
by  nutrition,  and  by  tonics  when  possible. 

Serum  Treatment. — The  use  of  streptolytic  serum  in  doses  of  10  to  30 
cubic  centimeters  is  well  worth  trying.  Antistreptococcus  serum  (10  to 
50  cubic  centimeters)  can  be  injected  in  daily  doses  of  10  cubic  centi- 
meters, or  the  dose  may  be  given  every  two  or  three  days. 

Ascites. 

This  is  an  accumulation  of  clear  serum  in  the  peritoneal  cavity.  When 
it  is  very  severe  there  is,  in  addition  to  the  uniform  distention  of  the 
abdomen,  a  superficial  enlargement  of  the  veins.  This  is  especially  noted 
around  the  veins  of  tlie  umbilicus. 


ASCITES  DUE  TO  PERITONITIS.  359 

Causes. — Pressure  iiiioii  the  vena  cava,  or  chronic  heart  or  lung 
trouble,  such  as  pleurisy,  may  give  rise  to  ascites.  In  extreme  leukgemia, 
anaemia,  or  kidney  disease  ascites  may  be  present. 

Diagnosis. — The  fluid  can  best  be  made  out  l)y  tapping  the  aljdomen 
and  noting  the  transmission  of  the  wave.  On  tapping  the  abdomen  with 
one  hand  and  pressing  the  other  firmly  against  the  opposite  side,  a  wave  of 
fluctuation  can  be  made  out. 

The  symptoms,  prognosis,  and  treatment  will  be  considered  in  the 
article  on  "Ascites  Due  to  Peritonitis." 

Ascites  Due  to  Peritonitis. 

In  the  majority  of  cases  ascites  is  caused  by  tubercular  peritonitis. 
This  condition  resembles  in  its  clinical  and  pathological  aspects  subacute 
or  chronic  pleurisy  with  effusion,  or  subacute  pericarditis. 

Etiology. — No  definite  cause  and  no  specific  agent  has  yet  been  deter- 
mined. Most  of  the  cases  are  associated  with  or  follow  rheumatism,  mea- 
sles, or  exposure  to  cold,  and  in  rare  instances  injury  to  the  affected  parts. 
It  is  also  seen  associated  with  diseases  of  the  kidney,  liver,  and  intestines. 

Pathology. — The  pathological  lesions  are  very  few.  The  effusion  is 
usually  of  a  greenish  color.  In  addition  to  the  serum  there  is  fibrin,  and 
in  some  instances  adhesions.  In  some  cases  all  the  serous  membranes  of 
the  body  seem  to  participate  and  show  evidences  of  inflammatory  condition. 

'Symptoms. — The  early  symptoms  of  ascites  consist  of  general  malaise. 
A  child  will  have  a  poor  appetite,  complain  of  headache,  and  sometimes 
constipation.  In  other  cases  diarrhoea  may  exist.  Pain  is  not  present  as 
a  rule.  The  abdominal  distention  comes  on  gradually  and  progresses.  The 
distention  is  usually  the  first  symptom  noted  by  the  mother.  The  fluid 
can  best  be  made  out  by  tapping  the  abdomen  as  described  in  the  foregoing 
article  on  "Ascites."  Fever  is  usually  absent,  although  there  may  be  an 
evening  temperature  of  101°  F. 

Prognosis. — The  prognosis  is  fair  as  a  rule.  I  have  seen  many  cases 
of  ascites  recover,  leaving  no  trace  of  the  former  trouble  behind.  A  cautious 
prognosis  is  advised  if  a  tuberculous  process  is  suspected. 

Treatment. — General  Treatment :  Such  children  must  be  put  to  bed. 
The  diet  should  consist  of  concentrated  liquid  food.  No  solid  meats  should 
be  permitted.  Milk,  if  not  well  borne,  should  be  peptonized  or  fermented. 
Buttermilk  may  be  recommended.  Fresh  air  and  sponge  bathing  should  be 
remembered  as  important  hygienic  factors. 

The  body  should  be  well  protected  to  avoid  chilling  the  surface. 

Treatment  of  the  Effusion. — Small  doses  of  calomel  or  podophyllin 
may  be  givc^  until  liquid  stools  are  produced.  Diuretics  such  as  cream  of 
tartar,  lemonade,  or  diuretin,  in  5-grain  doses,  will  stimulate  the  action  of 
the  kidneys  and  thus  lessen  indirectly  the  serous  effusion  in  the  abdomen. 


360  DISEASES  OF  THE  PERITONEUM. 

Iodide  of  sodium  in  3-  to  10-  grain  doses  should  be  given  three  times  a 
day  to  promote  absorption.  It  may  be  combined  with  iron  in  the  follow- 
ing manner : — 

IJ   Ferri  et  kali  tartaric   1   drachm 

Sodium   iodide 1  drachm 

Elix.  of  lactopeptin,  q.  s.  ad 2  ounces 

Sig. :      One  teaspoonful  three  times  a  day. 

Tapping  the  Abdomen. — Aspirating  the  liquid  by  means  of-  a  trocar 
and  cannula  is  a  valuable  means  of  emptying  the  liquid.  It  is  especially 
indicated  if  symptoms  of  dyspnoea  due  to  pressure  on  the  diaphragm  are 
noted. 

If  relapse  occurs  and  the  liquid  continues  to  accumulate  after  several 
aspirations,  then  surgical  treatment  will  be  necessary.  The  occasional  good 
results  seen  in  tubercular  peritonitis  after  a  laparotomy  should  be  remem- 
bered. 


CHAPTER  VI. 

DISEASES  OF  THE  GENITAL  ORGANS. 

Hernia.^ 

PIerxia  is  occasionally  seen  in  tlie  new-born  baby.  It  is  overlooked 
in  a  good  many  cases  until  the  size  of  the  tumor  indicates  that  something 
is  abnormal,  as  there  are  no  special  symptoms  (see  article  on  "Hygiene  oi 
tiie  Infant''  in  the  "Xew-ljorn  Infant"'). 

"In  congenital  hernia  proper,  anatomical  conditions  favoralde  to  vis- 
ceral escape  always  tend  to  permanent  spontaneous  cure  in  infancy  and 
early  cliildhood.  At  birth  the  spermatic  vessels  are  deeply  covered  by  a 
thick  layer  of  adipose  tissue.  The  dartos  and  cremaster  are  then  highly 
developed,  giving  the  scrotum  dimensions  cpiite  out  of  proportion  in  size 
to  what  they  are  in  adult  life.  Serous  cysts  of  the  tunica  spermatica  and 
of  the  tunica  vaginalis  being  very  common,  this  condition  also  with  the 
scrotum  fullness  may  simulate  hernia  so  closely  that  it  is  only  by  a  most 
painstaking  examination  we  are  enabled  to  exclude  them.  On  the  other 
hand,  a  small  fringe  of  omentum  may  come  down  with  the  cord  and  be 
completely  overlooked." 

Thomas  H.  Manley,  in  his  monograph  on  "Hernia  and  its  Treatment," 
says :  "The  prevalent  custom  of  applying  a  band  or  binder  around  the 
abdomen  should  be  condemned.  It  conserves  no  useful  purpose;  the  only 
excuse  for  it  at  all  is  that  it  retains  the  envelopes  of  the  funis  in  position. 
If  this  firm,  inelastic  compression  does  not  in  many  cases  directly  cause 
hernia  in  those  predisposed  to  it,  I  am  confident  it  often  very  seriously 
interferes  with  spontaneous  cure,  by  the  increasing  pressure  which  it  pro- 
duces against  the  abdominal  walls.  In  the  herniated  infant  this,  then, 
should  be  cast  aside,  the  dressing  for  the  navel  string  being  held  in  position 
by  adhesive  straps  or  tapes  passed  around  the  body.  x\fter  the  desiccated 
remnant  of  the  cord  has  dropped  off  nothing  whatever  in  the  way  of  a 
girth  should  be  worn  around  the  abdomen,  but  the  garments,  when- the 
erect  attitude  is  taken,  should  be  all  carried  from  the  shoulders,  thereby 
the  feeblest  possible  action  l)eing  given  to  the  diaphragm  and  the  organs 
of  digestion.  Occasionally  we  see  one  side  of  the  scrotum  occupied  by  a 
hernia  l)efore  the  testicle  has  descended.  Congenital  hernia  is  very  rare 
in  females.    In  the  female  the  umbilical  heniia  is  more  common." 

Causes. — A  calculus  in  any  portion  of  the  urethra  or  a  phimosis  or 
atresia  of  the  urethral  canal  may  cause  powerful  contractions  of  the  ab- 


For  Umbilical  Hernia  see  chapter  (in  "Diseases  of  the  Intestines.'" 

(3G1) 


362  DISEASES  OF  THE  GENITAL  ORGANS. 

dominal  muscles,  resulting  in  a  hernia.  Coughing,  especially  whooping- 
cough,  frequently  produces  hernia.  Constant  straining  efforts  during  con- 
stipation or  when  diarrhoea  persists  frequently  end  in  hernia. 

Symptoms-. — In  male  infants  a  tumor  that  is  soft  and  round  will  be 
found  in  the  scrotum.  The  testicle,  although  at  times  difficult  to  feel,  is 
usually  felt  above  or  behind  the  swelling.  This  swelling  consists  of  a  loop 
of  intestine;  rarely  the  peritoneum  descends  with  it.  By  placing  the  child 
on  its  back  the  swelling  can  easily  be  pushed  into  the  abdomen  through  the 
abdominal  ring.  There  is  always  a  gurgling  sound,  which  is  characteristic 
of  hernia. 

Diagnosis. — Hernia  is  frequently  mistaken  for  hydrocele.  Both  h}'- 
drocele  and  hernia  are  sometimes  found  in  the  same  case.  The  following 
differential  points  are  well  worth  noting: — 

Table  No.  41. 
Hydrocele.  Hernia. 

1.  Translucent  by  transmitted  light.  1.  Is  opaque. 

2.  Always    dull    on    percussion.  2.  Always   resonant. 

3.  When    reduction    is    possible    the  3.  The    hernia    passes    back    quickly 

fluid    passes    back    slowly    and  and     gives     the     characteristic 

noiselessly.  gurgling  sound. 

4.  No   impulse   on   coughing.  4.  An     impulse    can    be     felt    when 

patient   coughs. 

5.  The  ring  is  empty.  5.  The  ring  is  filled  with  the  neck  of 

the  tumor. 

Prognosis. — This  is  usually  good.  Children  rarely  have  strangulation 
as  we  find  it  in  adults.  Most  of  the  cases  of  hernia  seen  by  me  in  children 
recovered  with  the  aid  of  a  properly  fitting  truss.  At  times  nothing  but  an 
operation  will  cure  the  case. 

Treatment. — The  diet  should  be  regulated.  If  any  apparent  cause 
exists,  such  as  proloiiged  diarrhoeas  with  tenesmus,  constipation,  or  cough, 
the  same  should  be  treated.  If  a  whooping-cough  exists  the  proper  treat- 
ment must  be  instituted  before  mechanical  appliance  is  ordered.  This 
consists  chiefly  in  relieving  the  hernia  with  a  truss.  My  own  experience 
has  ))een  rather  good  by  having  a  rubber  sponge  with  a  rough  surface  made 
to  include  the  hernia.  This  should  be  held  in  place  by  the  usual  strap 
going  around  the  body.  The  leather  covered  or  the  celluloid  front  pads 
are  continually  slipping;  hence,  not  so  well  adapted  for  children.  The 
hygiene  should  be  well  considered  in  a  child.  A  truss  on  a  diapered  infant 
is  a  nuisance ;  it  cannot  be  kept  clean ;  hence,  every  nurse  or  mother  should 
be  instructed  regarding  the  sensitive  skin  and  the  danger  of  causing  irri- 
tation from  moistnre.  Every  mother  should  be  taught  to  watch  the  infant 
when  it  cries  or  strains  to  prevent  the  truss  from  slipping. 


niLMOSIS.  3G3 

Surgical  Treatment . — With  modern  aseptic  methods  there  is  little 
or  no  risk  in  an  operation.  The  success  of  the  Bassini  operation  is  so 
iiiiifunn  that  I  have  seen  dozens  of  children  operated  with  no  fatalities. 
For  the  details  of  this  surgical  method  I  would  refer  the  reader  to  text- 
books on  surgery. 

Hydrocele. 

"The  testicle  in  its  descent  is  surrounded  by  a  serous  membrane 
described  by  some  authors  as  a  serous  pouch.  When  this  pouch  fills  with 
Fennn  it  is  called  a  hydrocele.  Xormally  a  few  drops  of  serum  are  found 
in  the  tunica  vaginalis  propria.  Larger  accumulations  are  met  with  in 
more  than  10  per  cent,  of  male  infants,  mostly  on  the  right  side,  seldom 
on  both.  In  the  majority  of  cases  there  is  no  longer  a  communication 
with  the  abdominal  cavity.  When  it  remains  a  hernia  may  complicate 
the  hydrocele  and  the  diagnosis  be  more  difficult,  because  the  fluid  is  apt  to 
return  occasionally  into  the  abdomen.  Spontaneous  absorption  is  not  very 
rare,  but  suppuration  is  uncommon.'' 

Treatment. — Under  aseptic  precautions  a  sterilized  needle  or  trocar 
should  be  introduced.  By  this  means  the  serum  can  be  removed.  This 
simple  method  has  frequently  resulted  in  a  cure.  When  the  hydrocele  fills 
up  again  the  injection  of  a  few  drops  of  tincture  of  iodine  or  Lugol's  solu- 
tion, or  pure  carbolic  acid  after  the  serum  has  been  withdrawn,  will  usually 
prove  successful.  Operations  are  rarely  required,  although  they  are  indi- 
cated if  this  milder  form  of  treatment  proves  unsuccessful. 

Adherent  Prepuce. 

Congenital  agglutination  of  the  prepuce  and  the  glans  penis  is  occa- 
sionally reported.  The  majority  of  cases  seen  are  acquired  conditions. 
Smegma  frequently  collects  under  the  foreskin  when  the  same  is  not  prop- 
erly cleaned. 

Treatment. — With  a  blunt  probe  an  adherent  prepuce  can  be  loosened 
from  the  glans  penis.  The  smegma  should  -be  removed  and  the  parts 
lubricated  Avith  albolene  or  olive-oil.  The  mother  or  nurse  should  be 
instructed  to  oil  these  parts  and  thoroughly  separate  the  prepuce  so  that 
new  adhesions  do  not  form.  If  this  trouble  recurs  then  circumcision  is 
indicated. 

Phimosis   (Circumcision). 

Phimosis  is  due  to  a  narrowing  or  contraction  of  the  prepuce  so 
that  the  foreskin  is  jn-evented  from  l)eing  drawn  back  over  the  glans 
penis.  A  tight  prepuce  or  an  elongated  prepuce  is  a  constant  source  of 
irritation.  Bed  wetting  is  a  very  frequent  symptom  of  this  condition. 
There  is  an  itching  and  an  irritation  which  frequently  lead  to  bad  habits. 
The  sensitive  conditioii  sometimes  causes  priapism,  and  this  may  lead  to 


364  DISEASES  OF  THE  GENITAL  ORGANS. 

masturbation.  Night  terrors  and  insomnia  are  frequently  caused  by  this 
condition.  Phimosis  is  sometimes  an  exciting  cause  of  chorea  and  various 
nervous  diseases. 

Symptoms. — Such  children  invariably  suffer  with  anaemia.  They  are 
peevish  and  restless  and  constantly  irritable.  The  main  symptoms  are  a 
series  of  irritations  caused  by  the  tight  foreskin  as  outlined  above.  In 
exceptional  instances  strong,  healthy  children  may  not  show  any  symptoms 
of  this  condition. 

The  following  case  was  seen  by  me  in  private  practice : — 

A  boy,  4  years  old,  has  always  been  in  apparently  good  health.  He  was 
breast-fed,  well-nourished,  and  showed  no  evidence  of  rickets.  His  mother  com- 
plained to  me  that  the  child  had  a  "weak  bladder,"  that  he  could  not  hold  his  urine, 
especially  at  night.  He  was  restless  and  peevish,  and  tossed  about  in  his  sleep. 
On  examination  I  found  a  phimosis  existed.  The  prepuce  did  not  slip  over  the 
glans,  and  the  child  cried  as  though  in  pain  Avhenever  the  genitals  were  touched. 
I  advised  stretching  the  foreskin,  and  this  was  done  every  few  days,  with  some  degree 
of  success,  for  the  period  of  about  three  months.  The  cliild  improved.  When  seen 
again  about  one  year  later  the  symptoms  of  nervousness,  and  restlessness  reappeared. 
I  then  advised  circumcision.  With  the  assistance  of  Dr.  John  H.  Wurthman,  who 
administered  chloroform,  the  prepuce  was  removed,  the  parts  were  dusted  Avith 
europhen,  and  the  wound  healed  per  p^-iman.  The  child  improved  gradually  and  is  a 
good  healthy  child  to-day. 

Treatment. — The  treatment  outlined  in  the  case  above  described  is  the 
only  one  that  should  be  used :  First,  stretching  the  prepuce,  and,  secondly, 
if  this  does  not  afEord  relief,  circumcision. 

Operation. — A  simple  method  is  to  make  an  incision  or  cut  the  dorsum 
of  the  prepuce  with  a  scissors.  After  this  incision  is  made  we  invariably 
have  another  skin  to  divide,  which  is  the  mucous  membrane.  Unless  this 
is  also  incised  we  cannot  expect  relief  from  the  constriction.  As  a  rule  small, 
cheese-like  particles,  called  smegma,  will  be  found,  which  must  be  cleaned 
away.  Then  follows  the  surgical  treatment,  such  as  checking  haemorrhage, 
if  the  same  is  profuse.  In  rare  cases  one  or  more  stitches  may  be  necessary 
to  control  the  bleeding.  I  invariably  use  a  piece  of  sterile  gauze  saturated 
with  Monsel's  solution  immediately  after  the  operation,  then  dust  the  parts 
with  europhen.  Great  care  should  be  used  to  avoid  infection  from  a  case 
of  diphtheria  or  erysipelas.  It  is  safer  to  have  a  surgeon  supervise  or  per- 
form the  operation  than  to  run  the  risk  of  infection. 

Paraphimosis. 

This  is  a  condition  caused  by  the  swelling  of  the  glans  or  by  an  abnor- 
mally small  preputial  orifice. 

Treatment. — Have  the  thumb  and  finger  of  one  hand  pressing  on  the 
glans;  with  the  other  hand  an  attempt  should  he  made  to  draw  the  prepuce 


CRYPTORCHIDISM.  3  Go 

back  in  position.  In  some  cases  immei'sing  the  parts  in  very  warm  water 
for  several  minutes  lias  served  me  very  well.  If  the  parts  are  very  tender 
a  spray  of  ethyl  chloride  can  be  used  with  advantage  before  the  attempted 
reduction.  When  the  parts  are  very  oedematous  then  puncturing  the  sur- 
face to  relieve  the  serum  will  sometimes  yield  good  results.  At  times  sur- 
gical relief  may  be  demanded. 

Hypospadias. 

The  urethra  sometimes  opens  on  the  under  side  of  the  penis.  This  is 
always  a  congenital  condition. 

A  case  of  this  kind  was  seen  be  me  in  consultation  with  Dr.  Julius  Brandeis,  of 
New  York  City.  When  I  saw  this  infant  it  was  three  days  old  and  apparently 
suffering  pain.  The  bladder  was  distended,  and  the  infant  had  not  urinated, 
according  to  the  history  given,  since  it  was  born.  An  examination  showed  a 
hypospadias.  The  urethral  orifice  in  the  glans  penis  was  absent.  With  the  aid 
of  diuretics  and  a  warm  hip  bath  the  infant  urinated.  I  have  seen  this  child  many 
times  since.    He  is  now  able  to  walk  and  talk  and  suffers  no  inconvenience. 

The  treatment  is  radical — by  means  of  plastic  surgery. 

Epispadias. 

In  this  condition  the  opening  of  the  urethra  is  on  the  superior  surface 
of  the  penis.     It  is  less  frequently  met  with  than  hypospadias. 

The  treatment  is  distinctly  surgical  and  requires  a  plastic  operation. 

Cryptorchidism    (Undescended  Testicle). 

The  testes  usually  descend  into  the  scrotum  during  the  ninth  montli 
of  pregnancy.  In  some  children  the  testicles  may  remain  in  the  inguinal 
canal  or  even  in  the  abdomen. 

Ralph  C.  was  referred  to  me  by  Dr.  W.  Freudenthal.  He  was  a  well-nourished, 
healthy  child.  Was  breast-fed  and  in  apparent  good  health  until  two  years  ago. 
He  suffered  with  cough,  was  a  mouth  breather,  and  snored  at  night,  for  the  relief 
of  which  Dr.  Freudenthal  removed  his  adenoids.  The  child  was  brought  to  me  for 
the  relief  of  an  irritable  and  restless  condition.  His  mother  stated  that  he  scratched 
his  nose  and  appeared  to  have  a  pruritus  of  the  anus.  The  diagnosis  of  ascarides 
lumbricoides  was  made.  \Miile  examining  the  child  I  found  one  testicle  could  be 
palpated  in  the  scrotum  and  the  other  in  tlie  inguinal  canal.  By  pressure  on  the 
abdomen  it  would  descend.  Tliere  were  no  symptoms  directly  attributable  to  tliis 
condition. 

Treatment. — If  no  irritation  is  caused  then  let  it  alone.  If  a  false 
passage  lias  Ijcen  made  which  gives  rise  to  pain,  then  the  question  of 
removal  of  the  testicle  may  come  up.     The  case  then  is  distinctly  surgical. 


366  DISEASES  OF  THE  GENITAL  ORGANS. 

Obchitis. 

An  inflammation  of  the  testicle  is  a  rare  condition  in  infancy.  Cases 
have  been  reported  where  injury  caused  orchitis.  In  the  article  on  "Mumps" 
orchitis  is  mentioned  as  a  complication.  The  treatment  consists  in  rest  and 
ice-cold  applications  of  lead  and  opium.  Laxatives  are  indicated  to  open 
the  bowels  and  thus  help  relieve  the  inflammation. 

Urethritis  :    Vulvo-vaginitis. 

Vulvo-vaginitis  is  a  catarrhal  infectious  disease  involving  the  female 
genital  tract.    It  is  divided  into : — 

(a)    Simple  or  Catarrhal;  (5)    Gonorrhoeal. 

Simple  Vaginitis. 

The  normal  urethra  of  both  male  and  female  children,  also  the  vagina, 
frequently  has  a  simple  catarrh.  The  symptoms  noticed  are  those  of  swell- 
ing, inflammation  and  a  catarrhal  secretion. 

Etiology  and  Bacteriology. — Normally  the  vagina  contains  a  white 
diplococcus  which  is  not  decolorized  by  Gram. 

In  simple  catarrhal  vulvo-vaginitis  we  have  a  white  diplococcus  which 
also  is  not  decolorized  by  Gram. 

In  gonorrhoeal  vulvo-vaginitis  we  have  a  white  diplococcus  which  does 
not  decolorize  by  Gram,  and  in  addition  thereto  a  yellow  diplococcus  called 
D.  Flavus  (Bumm). 

These  germs  are  usually  found  in  conjunction  with  other  micro-organ- 
isms or  with  streptococci.  They  easily  stain  with  a  watery  solution  of  eosin 
and  counterstain  with  an  alkaline  aqueous  methylene  blue  solution. 

The  microscoi3ical  examination  shows  leucocytes,  epithelium,  and 
various  micro-organisms;  never  gonococci. 

Symptoms.- — The  jjarts  are  usually  sensitive  to  pressure. 

Children  who  are  old  enough  complain  of  pain  on  urination,  and  also 
urinate  very  frequently.  In  very  3^oung  children  it  is  impossible,  in  fact, 
unnecessary,  to  make  a  vaginal  or  uterine  examination. 

This  disease  may  last  for  months,  especially  so  if  the  body  is  in  a 
subnormal  condition. 

This  simple  catarrh  affecting  the  vulvo-vagina  is  highly  contagious, 
hence  each  case  should  be  strictly  isolated. 

Children  so  afflicted  should  sleep  alone. 

GONORRIICEAL  VAGINITIS. 

Gonorrhoeal  vulvo-vaginitis  is  frequently  met  \jtith  in  practice.  As  a 
rule  it  occurs  among  poorer  classes  where  families ^are  crowded  and  un- 
sanitary.    Frequently  the  infection  is  transmitted  from  the  adult  to  the 


GONORiaia<:Ai.  vaginitis.  367 

child  by  sleeping  in  an  infected  bed.  Cases  are  on  record  where  a  mother 
suffering  with  gonorrhoeal  vulvo-vaginitis  has  infected  her  child  while 
sleeping  with  it. 

Etiology. — The  slightest  abrasion  of  the  skin  will  permit  the  entrance 
of  the  gODOcoccus.  Cases  have  been  reported  in  which  a  healthy  person  was 
infected  by  taking  a  bath  in  the  same  tub  in  which  a  person  affected  -with 
gonorrhoea  had  bathed  the  day  previous.  It  is  a  well-known  fact  that  the 
gonococcus  will  live  twenty-four  hours,  hence  these  germs*  will  persist  in  the 
tub  and  can  transmit  infection.  For  this  reason  a  separate  tub  should 
be  procured  while  gonorrhoeal  disease  exists. 

Bacteriology. — Gonorrhoeal  vaginitis  is  caused  by  the  presence  of  the 
gonococcus.  It  is  necessary,  however,  to  subject  the  gonococcus  described 
by  ISTeisser  to  the  Gram  method  of  staining.  The  diplococcus  found  in  the 
normal  urethra  can  easily  be  differentiated  by  su])jecting  the  same  to  the 
Gram  stain.  Normally  the  gonococcus  has  never  been  found  in  the  vulvo- 
vaginal tract  or  in  the  normal  urethra.  The  gonococcus  can  easily  be 
stained  with  a  2  per  cent,  alcoholic  methylene  blue  solution. 

Mode  of  Infection. — Direct  transmission  of  infected  matter  from  adults 
to  children  has  been  known  to  occur.  Infected  clothing,  especially  bed 
linen,  has  transmitted  this  disease. 

In  rare  instances  the  infection  has  taken  place  directly  during  the 
sexual  act.  There  is  a  popular  superstition  that  when  an  adult  male  has 
gonorrhoea  he  will  be  cured  by  raping  a  healthy  child.  An  instance  of  this 
kind  has  occurred  in  my  practice. ' 


Fig.  111. — Gonococcus.  (Gonorrhoeal  Pus.)  Stained  one-half  minute 
with  methylene-blue.  c,  Free  in  gi'oups.  6,  Enclosed  in  pus  cells.  Leitz 
ooular  I.     Oil  imersion  Vi2-      (Lenhartz-Brooks. ) 


368  DISEASES  OP  THE  GENITAL  ORGANS. 

A  little  girl,  6  years  old,  apparently  healthy,  was  infected  by  an  adult  suffering 
with  gonorrhoea.  She  suffered  continuously  for  over  four  months  until  brought  to 
me,  when  her  vulva,  vagina,  and  urethra  were  one  mass  of  inflammation.  There 
was  a  greenish-yellow  discharge.  The  bacteriological  examination  showed  diplococci 
in  the  leucocytes. 

The  child  was  put  to  bed  and  a  sterilized  pad  applied  over  the  genitals.  This 
pad  was  changed  every  four  hours.  A  sitz  bath  of  1  to  2000  warm  bichloride  was 
ordered  morning  and  evening,  lasting  twenty  minutes.  A  vaginal  injection  of  10  per 
cent,  argyrol  solution  was  given  immediately  after  each  bath.  Internally  iron 
was  given.  The  discharge  continued  eleven  days  and  everything  seemed  well.  A 
reinfection  evidently  took  place  four  days  after  having  stopped  the  active  treatment, 
as  the  discharge  appeared  with  renewed  vigor.  The  child  was  again  carefully 
treated  with  astringents.  The  discharge  persisted  for  three  months,  when  it  was 
finally  cured. 

Complications. — The  Eye:  The  danger  of  transmitting  gonorrhoea! 
infection  by  the  hands  from  the  genitals  to  the  eyes  must  always  be  re- 
membered. That  this  form  of  infection  is  not  without  danger  is  well 
known.  At  the  Eiverside  Hospital  in  the  scarlet  fever  wards,  during  the 
summer  of  1902,  I  saw  a  child  that  was  totally  blind,  the  result  of  a  gonor- 
rhoeal  infection. 

The  Joints. — We  occasionally  meet  with  symptoms  of  inflammation 
involving  one  large  joint;  this  is  called  monarthritis.  An  inflammation 
of  this  kind  usually  means  gonorrhoeal  infection. 

The  Heart. — ^When  the  gonococcus  enters  the  circulation  it  frequently 
attacks  the  valves  of  the  heart.  Valvular  lesions  are  similar  to  joint  lesions ; 
hence  we  must  not  be  surprised  to  see  cases  reported  in  which  a  gonorrhoea 
started  at  the  genital  tract,  entered  the  circulation,  and  involved  the  heart. 
A  case  of  this  kind  was  reported  by  Leyden,  of  Berlin. 

Pyelitis  caused  by  an  extension  of  this  infection  from  the  urethra  may 
end  fatally.  An  infection  may  spread  from  the  vagina  into  the  uterus  and 
set  up  a  salpingitis  and  end  fatally.  On  the  other  hand,  this  disease,  if 
neglected,  may  assume  a  chronic  tendency  and  cause  sterility,  so  that  a 
guarded  prognosis  should  be  given  in  every  case  until  the  infection  is  modi- 
fied and  the  outlook  is  good.     (Eead  article  on  "Pyelitis.") 

Vicarious  Menstruation. 

Some  children  have  a  periodical  nosebleed,  recurring  every  three  or 
four  weeks.  In  some  cases  there  is  a  considerable  flow  of  blood,  lasting 
between  two  and  five  days.  In  making  the  diagnosis  it  is  important  to 
exclude  all  diseases  due  to  local  causes,  such  as  polypus  or  haemophilia. 
In  one  case  seen  by  me  (see  chapter  on  "Syphilis")  fatal  haemorrhage 
resulted  in  a  case  of  congenital  syphilis. 

The  cause  is  unknown. 

Treatment. — The  body  should  be  strengthened  and  iron  given  inter- 
nally. A  change  of  air  to  the  seashore  or  mountains  will  strengthen  the 
body  and  frequently  relieve  this  condition. 


MENSTRUATION.  3(jy 


Menstruation  Precox. 


We  occasionally  see  girls  from  6  to  10  years  of  age  with  regular  men- 
struation. Literature  record^  numerous  cases  of  children  from  2  to  5  years 
of  age  with  regularly  recurring  menstruation.  Such  menstruation  lasts  sev- 
eral days  or  in  some  instances  several  hours.  As  a  rule,  such  children  are 
delicate,  tuberculous,  or  syphilitic. 

Symptoms.— There  is  usually  pain  in  the  abdomen  similar  to  colic, 
restlessness,  and  a  series  of  nervous  symptoms.  Such  children  are  hard 
to  please. 

Diagnosis. — It  is  necessary  to  exclude  local  causes,  such  as  papil- 
lomatous or  polypoid  excrescences.  I  have  previously  referred  to  hgemophilia 
and  to  syphilis  as  a  possible  cause.  Local  causes,  such  as  masturbation  or 
traumatism,  must  be  excluded.  As  a  sequela  to  acute  infectious  diseases, 
we  frequently  have  vaginal  catarrh.  This  discharge  may  sometimes  be 
mixed  with  blood.  The  diagnosis  depends  on  the  regularity  of  the  periods, 
recurring  every  three  or  four  weeks. 

Treatment. — Warm,  demulcent  drinks  and  the  avoidance  of  cooling 
liquids.    The  child  should  be  kept  in  bed  and  warmly  dressed. 

If  the  bleeding  is  very  profuse,  then  5  to  10  drops  of  fluid  extract  of 
ergot  (Squibb's),  or  hydrastinin  hydrochlorate,  ^/^o  to  ^/oo  grain,  three 
times  a  day,  may  be  given.  An  ice-bag  over  the  abdomen  will  frequently 
relieve  severe  pain  and  check  profuse  bleeding. 


24 


CHAPTER  VII. 
DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

The  Kidney.^ 

The  kidneys  of  an  infant  are  proportionately  larger  than  in  adult  life. 
They  are  also  situated  lower  than  in  the  adult.  The  large  size  of  the  liver 
in  infancy  is  the  reason  for  the  difference  in  position  of  the  right  and  left 
kidney.  The  right  kidney  is  situated  lower  than  the  left.  The  suprarenal 
capsules  are  much  larger  than  in  the  adult.  After  the  second  year  the' 
kidneys  assume  the  position  usually  occupied  by  the  adult  kidneys. 

Acute  Nephritis  (Acute  Glomerulo-Nephritis  ;  Acute 
Bright's  Disease). 

Primary  nephritis  is  by  no  means  ,a  rare  condition  in  children.  In 
the  majority  of  text-books  nephritis  is  described  as  the  complication  of 
infectious  diseases.  It  is  true  that  it  is  most  often  seen  following  the 
acute  infectious  diseases.  In  primary  nephritis  the  source  of  infection  is 
sometimes  hard  to  trace.  Pathogenic  bacteria  can  reach  the  kidneys  through 
the  circulation  and  thus  set  up  nephritis. 

Etiology. — ^The  influence  of  exposure,  "taking  cold/'  must  be  looked 
upon  as  an  associated  factor  in  the  causation  of  this  disease. 

Comby-  explains  this. as  follows: — 

In  the  absence  of  a  specific  process,  such  as  scarlatina,  diphtheria,  etc.,. 
we  are  led,  upon  the  occurrence  of  acute  simple  nephritis,  to  suspect  the 
mfluence  of  cold.  The  action  of  cold,  however,  is  not  always  direct.  In 
nephritis,  as  in  pneumonia,  cold  alone  does  not  cause  the  disease.  It  en- 
feebles the  organism,  increases  its  receptivity,  augments  the  virulence  of 
microbes,  and  opens  the  gates  by  which  they  enter.  Children  carry  within 
themselves,  in  the  mouth,  pharynx,  and  nasal  passages,  various  microbes,. 
which  only  await  an  opportunity  of  wakening  into  activity.  This  opportu- 
nity is  afforded  them  by  the  impression  of  cold. 

The  sore  throat  which  so  often  precedes  nephritis  constitutes  a  first 
step  toward  the  invasion  by  pathogenic  microbes.  The  epithelial  barrier 
is  broken  down,  the  micro-organisms  reach  the  lymphatic  glands,  where 
they  are  often  arrested  or  may  continue  their  progress,  passing  into  the- 


'^The  urine,  its  physiological  and  pathological  condition,  is  described  in  detail 
in  the  chapter  on  "Urine,"  Part  XII. 

-  "Nephrite  Aigue  Simple  des  Enfants,"  par  le  Dr.  J.  Comby,  La  M6decine- 
Moderne,  December  1,  1897. 

.       (370) 


ACUTE  NEPHRITIS.  37I 

circulation,  and  finally  excite  a  distant  inflammation  which  may  be,  accord- 
ing to  circumstances,  a  pneumonia,  an  endocarditis,  or  nephritis,  etc. 

In  some  cases  an  apparently  most  trival  angina  becomes  complicated 
with  swollen  cervical  glands,  and,  subsequently,  with  acute  nephritis,  etc. 
Cases  have  been  described  as  glandular  fever,  or,  in  other  words,  acute 
adenitis,  symptomatic  of  pharyngeal  infection,  in  which  nephritis  has 
developed,  superadded  to  the  original  disease,  which  it  finally  survives. 
These  complications  are  not  fortuitous,  but  are  linked  together  in  strict 
sequence. 

Pathology. — Inflammation  of  the  kidney  in  a  large  majority  of  cases 
commences  as  a  glomerulo-nephritis,  the  delicate  walls  of  the  capillaries, 
and  their  equally  delicate  epithelial  investment  being  the  earliest  to  suffer; 
and  instead  of  the  non-albuminous  urine,  one  laden  with  albumin  escapes. 
If  the  inflammation  still  progresses,  corpuscles,  especially  the  red,  make 
their  way  out  and  produce  smoky  or  bloody  urine,  the  naturally  high  pres- 
sure in  the  glomerulus  no  doubt  greatly  facilitating  the  diapedesis.  The 
casts  which  may  now  appear  consist  for  the  most  part  of  fibrin,  of  red  and 
white  corpuscles,  and  of  renal  dchris,  moulded  in  the  tubes. 

The  glomerular  disturbance  is  followed  by  that  of  the  rest  of  the  vas- 
cular net-work  and  of  the  gland  cells.  The  latter  become  swollen  and 
"clouded,"  and  are  readily  detached.  The  SAvollen  cells  may  occlude  the 
lumen  of  the  ducts  and  press  upon  the  vascular  tissue  without.  Or  the 
capillaries  are  congested  and  exudation  swells  the  intertubular  tissue.  In 
any  case  the  tissue  is  enlarged  and  softened.  Sometimes  during  life  the 
signs  of  nephritis  are  Avell  marked,  but  after  death  .the  anatomical  lesion 
appears  very  slight;  in  these  cases  comparison  with  a  normal  kidnej-,  both 
to  the  naked  eye  and  under  the  microscope,  is  invaluable,  as  then  some 
change  can  usually  be  detected. 

The  kidney  of  typhoid  and  diphtheria^  serve  as  examples,  although 
there  are  numerous  acute  specific  diseases  which  are  accompanied  by  ne- 
phritis and  albuminuria.  The  glomeruli  are  enlarged,  owing  to  swelling 
of  the  interstitial  substance  and  to  engorgement  of  the  capillaries'  and 
often  swelling  of  the  endothelial  cells;  there  is  in  addition  an  increase 
in  the  number  of  nuclei  in  the  glomeruli.  Bowman's  capsules  may  be 
slightly  distended,  their  endothelium  swollen  or  proliferating,  and  the 
spaces  occupied  by  fibrin  or  white  or  red  corpuscles.  There  may  be  an 
increase  in  corpuscles  around  the  roots  of  the  glomeruli.  The  tubules  may 
be  dilated,  the  epithelium  swollen  and  granular,  or  there  ma}''  be  some 
proliferation.  Casts  are  numerous,  though  usually  hyaline;  they  may 
consist  of  blood.  Small  hemorrhages  are  frequent,  especially  in  diph- 
theritic kidneys. 

Acute  nephritis  in  the  new-bom  has  been  described  by  Jacobi.^ 


*  New  York  Medical  Journal,  January,  1896. 


372  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

Symptoms. — Gastric  disturbances,  such  as  vomiting,  are  very  fre- 
quently noted.  As  a  rule  premonitory  symptoms  are  absent.  Nephritis  fre- 
quently begins  with  fever,  loss  of  appetite,  headache,  and  general  malaise. 
Swelling  of  the  face  is  sometimes  the  first  sign  of  trouble. 

The  urine  is  always  scanty  and  sometimes  contains  red  blood-corpus- 
cles, leucocytes,  and  casts.  The  urine  shows  the  evidence  of  acute  renal 
congestion  and  is  always  alljuminous.  In  grave  cases  there  are  frequent 
■efforts  to  pass  urine,  and  these  attempts  are  attended  with  pain.  With  great 
•difficulty  the  child  expels  a  few  drops  of  dark  colored  urine.  According 
to  the  severity  of  the  case  these  symptoms  subside  after  a  period  varying 
from  ten  to  thirty  days.  Irregularity  of  the  pulse  is  frequently  noted,  and 
should  alw^ays  be  looked  upon  as  an  evidence  of  toxaemia.  It  is  a  grave 
symptom. 


Fig.    112.— Nephritis   Complicating  Diphtheria.     Case  seen  by  me 
at  the  Willard  Parker  Hospital.      (Original.) 

The  action  of  the  heart  should  be  closely  followed  in  every  case  of 
nephritis. 

Prognosis. — This  is  usually  good.  If  treatment  is  neglected  in  an 
acute  nephritis,  a  chronic  nephritis  will  result.  In  rare  instances  a  general 
toxaemia  may  cause  convulsions  and  death. 

Keptiritis  a  Complication. — This  disease  may  accompany  or  follow 
scarlet  fever  or  diphtlieria.  It  is  also  occasionally  seen  in  most  infections' 
•diseases  such  as  typhoid,  measles,  varicella,  pneumoiiia,  influenza,  malaria, 
meningitis,  and  empyema. 

In  a  study  of  gastro-cnteritis  made  by,Baginsky,  the  frequent  asso- 
•ciation  of  nephritis  was  noted.  This  author  found  that  the  bacterium  coli 
could  frequently  cause  acute  nephritis. 

Elaine  K.,  a  girl,  5  years  old,  had  vomiting,  followed  by  an  eruption  of  scarlet 
fever  covr'ring  the  entire  body.  The  rash  was  distinct  for  three  days  and  then 
faded.     The  physician  in  attendance  said  it  was  a  case  of  mild  scarlet  fever.     The 


SECONDARY   X K I'll  Ki  118.  373 

child  was  up  and  about  during  tlio  second  week  following  tlie  eruption.  The  stomach 
was  not  carefully  guarded,  as  the  child  was  given  a  too  liberal  diet.  On  the  twelfth 
day  from  the  beginning  of  her  illness  she  suddenly  had  what  the  family  called  a 
sinking  spell.  Evidences  of  heart  weakness  were  noted.  Two  days  later,  or  on 
the  fourteenth  day  of  her  illness,  she  was  again  put  to  bed.  At  this  time  sha  com- 
plained of  pains  in  her  joints.  The  glands  of  the  neclc  were  swollen.  The  urine 
was  somewhat  scanty.     On  the  seventeenth  day  she  had  three  very  severe  convulsions. 

Owing  to  the  careless  management  of  this  case,  tlie  family  discharged  the 
first  attending  physician.  LatcM-  llie  family  called  Dr.  H.  Peclmer,  who  saw  the 
severe  toxajmia  and  noted  the  anuria.  I  saw  this  case  twenty-one  days  after  the 
beginning  of  the  disease.  The  diagnosis  of  nephritis  was  easily  made.  Hardly  an 
ounce  of  urine  was  passed  during  the  day.  The  cliild  was  cedematous  and  had  the 
waxy  appearance  seen  in  acute  nephritis.  The  lieart  sounds  were  muffled.  The 
pulse-rate  was  slow  and  irregular.  The  temperature  was  very  slightly  elevated, 
although  a  severe  myocarditis  existed.  The  child  was  placed  in  bed,  under  the  care 
of  two  trained  nurses. 

Treatment. — Hot  packs,  diaphoretics,  and  diuretin,  in  doses  of  5  to  20  grains, 
three  and  four  times  a  day  were  given.  Hot  saline  colon  flushings  at  a  temperature 
of  115°  F.  were  ordered  to  stimulate  diuresis.  A  bland  liquid  diet  aided  by  liquids, 
lemonade,  and  cream  of  tartar,  formed  the  main  treatment.  The  child  made  a 
brilliant  recovery.  There  were  no  complications  after  the  disappearance  of  the 
nephritis. 

Secondary  ]S[epheitis. 

Secoiidan-  nephritis,  following  the  acute  infectious  disease?,  can  best 
be  studied  Ijy  taking  the  type  most  frequently  met  with,  namely,  post-scar- 
latinal nephritis.  (See  chapter  on  "Scarlet  Fever"  for  a  complete  descrip- 
tion of  this  condition.  Note  also  the  microscopical  appearance  of  the 
urine  in  the  same  chapter,  page  616.) 

Treatment. — Cream  of  tartar  lemonade,  a  teaspoonful  oi  cream  of 
tartar,  added  to  a  tumblerful  of  ordinary  lemonade,  and  sweeten.  This 
should  be 'given  freely.  Another  drug  that  has  served  me  very  well  is 
diuretin;  this  should  be  administered  in  doses  of  from  3  to  15  grains, 
depending  on  the  age.  This  can  be  repeated  every  three  or  four  hours, 
depending  on  the  severity  of  the  case.  When  diuretin  is  not  well  borne  by 
mouth,  I  give  it  in  the  form  of  suppositories  per  rectum. 

The  following  has  served  me  very  well  as  a  diuretic  in  nephritis  when 
the  urine  was  scanty : — 

'^  Potass,   citrat 2V-2  drachms 

Ext.  buchu.  fluid ^i-j  drachms 

Ext.  uva  ursi  fl 1   drachm  1  scruple 

Syr.  limonis   -  ounces 

Aqua    q-  s.  ad  4  ounces 

Sig. :     Teaspoonful  every  two  or  three  hoiu^s. 

Calomel  or  ])od(iphyllin.  in  small  doses.  \/.,i  grain,  repeated  every  two 
or  three  hours,  is  sometimes  valuable  in  this  condition.     Lithia  water  and 


374  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

the  alkaline  waters  are  generally  indicated.  An  infusion  made  by  scalding 
the  ordinary  parsley  root  (rad.  petrosilini),  using  about  one  teaspoonful 
of  the  chopped  root  to  a  teacupful  of  boiling  water,  strain  and  sweeten. 
This  can  be  given  in  large  quantities  whenever  the  child  is  thirsty.  Sweet 
spirit  of  niter  in  doses  of  %  teaspoonful,  gradually  increased,  for  a  child 
1  to  5  years  old,  and  repeated  every  three  hours,  is  a  safe  and  efficient 
diuretic. 

Jaborandi  or  its  alkaloid,  pilocarpine,  are  frequently  advised  as  diu- 
retics. I  have  frequently  seen  such  cardiac  depression  follow  their  admin- 
istration that  I  invariably  warn  against  their  use.  In  conclusion,  I  desire 
to  lay  great  stress  on  the  weakness  of  the  heart  frequently  noticed  after 
the  administration  of  the  hot-air  bath.  In  one  instance  where  I  was  called 
into  consultation,  the  child  .died  during  the  administration  of  such  a  bath. 

Perinephritis. 

An  acute  inflammation  involving  the  cellular  tissue  which  surrounds 
the  kidney,  as  a  rule  terminating  in  suppuration.  Some  cases  may  resolve 
without  suppuration. 

Etiology. — It  may  be  associated  with  or  due  to  suppurative  process  in 
the  kidneys.  It  is  also  found  in  tubercular  conditions.  The  most  frequent 
cause  undoubtedly  is  traumatism.  Idiopathic  conditions  are  frequently  a 
distinct  factor. 

Perinephritis  is  not  of  frequent  occurrence.  Townsend  gives  the  fol- 
lowing statistics :  "Nieden,  in  1897,  found  records  of  166  cases.  Twenty- 
three  of  these  were  under  15  years  of  age,  the  youngest  being  five  weeks 
old.  In  1880  Gibney  reported  a  total  of  28  cases;  the  ages  varied  from 
1%  to  15  years.  In  16  there  was  suppuration;  in  12,  no  suppuration:  In 
19  cases  no  cause  was  found;  in  8  cases  a  cause  was  given.  Fenwick  re- 
ports 76  cases :  4  children  under  10  years,  and  9  between  10  and  20  years, 
the  youngest  being  fourteen  months  old.  Kustre  makes  a  report  of  230 
cases,  24  under  10  years  of  age,  17  between  10  and  20  years.  Johnson,  in 
an  experience*  of  nine  years  in  Eoosevelt  Hospital,  saw  but  one  case  in  a 
child,  a  perinephritic  abscess  in  a  boy  of  10  following  a  fall,  not  complicated 
by  a  kidney  lesion.  Israel,  in  a  report  of  43  cases,  speaks  of  one  in  a 
patient  12  years  old." 

Out  of  3689  patients  treated  in  the  outdoor  department  of  the  Chil- 
dren's Hospital  for  the  Relief  of  the  Euptured  and  Crippled,  in  New  York, 
during  1894-1903,  only  6  cases  are  reported  by  Townsend. 

Pathology  and  Bacteriology.— As  a  rule,  80  per  cent,  of  the  primary 
cases  terminate  in  abscess.  In  secondary  cases  an  abscess  is  always  found. 
The  pathological  condition  is  the  same  as  is  found  in  every  acute  inflam- 
mation. The  pus  contains  either  the  streptococcus,  the  staphylococcus,  or 
colon  bacillus.     In  rare  instances  the  pneumococcus  and  the  typhoid  ba- 


PERINEPHRITIS.  375 

cillus  are  present.     In  tubercular  manifestations  the  tubercle  bacillus  will 
be  found. 

Symptoms. — A  child  that  has  been  in  good  health  will  suddenly  de- 
velop pain  in  the  region  of  the  kidney  near  the  vertebra.  The  pain  extends 
downward  and  simulates  sciatica.  Moving  the  body  increases  the  pain; 
hence  the  spine  is  generally  rigid.  For  this  reason  alone  many  cases  are 
mistaken  for  Pott's  disease.  There  will  also  be  fever,  the  temperature 
ranging  between  102°  and  104°  F.  If  the  child  is  old  enough  to  complain, 
then  chills  will  be  noted.  In  the  ileo-costal  region  there  is  usually  a  pal- 
pable tumor.  Children  so  afflicted  will  refuse  to  walk  on  the  affected  side, 
and  will  limp.  They  describe  the  pain  as  though  it  were  in  the  groin,  in 
the  hip,  or  sometimes  in  the  knee-joint.  If  pyelitis  complicates,  the  urine 
will  contain  pus.    Owing  to  the  passive  condition  there  is  constipation. 

A.  B.,  9  years  old,  complained  of  pain  in  the  gi'oin  and  also  in  the  back  on  the 
left  side.  He  limped  and  could  not  stand  on  his  left  leg.  He  complained  of  chills 
and  his  temperature  rose  to  103°  F.  He  urinated  very  frequently.  After  a  careful 
examination  the  urine  was  found  to  contain  nothing  abnormal.  The  boy  was  put  to 
bed.  The  bowels  were  flushed.  Owing  to  small  roseolar  spots  which  appeared, 
typhoid  fever  was  suspected.  The  blood  reaction  for  Widal  was  absent.  The  urine 
gave  no  diazo  reaction.  The  pain,  increased,  and  after  ten  days  of  expectant  treat- 
ment a  swelling  was  noted  in  the  loin. 

This  swelling  gradually  increased  in  size  until  it  was  as  large  as  a  hen's  egg. 
A  surgeon  was  called,  who  diagnosed  perinephritis.  An  incision  was  made  and  two 
ounces  of  pus  liberated.  The  wound  was  packed  with  sterile  gauze,  and,  with  rest, 
iron,  and  strychnine  internally,  the  boy  recovered  in  about  five  Aveeks. 

Diagnosis. — This  condition  may  be  confounded  with  hip-joint  disease, 
but  hip-joint  disease  develops  very  slowly  and  has  a  tendency  to  become 
chronic.  The  symptoms,  while  very  similar  in  perinephritis,  develop  sud- 
denly from  within  a  few  days  to  a  few  weeks,  and  recovery  may  occur  within 
a  few  weeks  after  the  first  symptoms  are  noted.  In  hip-joint  disease  the 
symptoms  extend  over  months  and  years. 

The  Blood. — An  important  diagnostic  point  is  the  increase  in  the  num- 
ber of  leucocytes,  such  as  we  find  in  purulent  conditions  in  other  parts  of  the 
body.    In  tuberculosis  there  is  no  leucocytosis  unless  sepsis  exists. 

Prognosis  and  Course. — Primary  perinephritis  runs  an  acute  short 
course  of  a  few  weeks  and  usually  terminates  favorably.  Gibney  reports 
28  cases,  all  of  which  recovered. 

Treatment. — Eest  in  bed  and  a  warm  poultice  over  the  affected  area  to 
hasten  suppuration.  The  abscess  should  be  treated  on  strict  surgical  prin- 
ciples. No  time  should  be  lost  when  fluctuation  is  felt,  owing  to  the  danger 
of  pus  burrowing  into  the  peritoneal  cavity. 

Eestorative  treatment,  such  as  diet,  fresh  air,  iron,  and  eodliver-oil, 
should  form  the  basis  of  the  building-up  process. 


376  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 


Pyelitis  (Pyelonephritis). 

This  condition  is  rarely  met  with  in  practice.  Literature  records 
isolated  cases.  Monti,  of  Vienna;  Baginsky,  Steffen,  and  Holt  are  among 
those  who  have  reported  cases  of  this  kind. 

Causes. — Pyelonephritis  occurs  at  all  ages,  but  is  more  common  in 
adult  males  than  in  the  young.  The  exciting  causes  in  adult  males  are 
stricture  of  the  urethra,  renal  calculi,  prostatic  diseases,  and  infection  by 
means  of  dirty  catheters.  That  girls  seem  to  have  been  favored  by  this 
disease  can  be  seen  by  referring  to  the  literature;  thus  Professor  Baginsky 
reports  three  cases,  all  girls,  in  the  Deutsch.  med.  Wocliensclirift,  1897, 
No.  25,  which  he  discussed  at  the  Verein  fiir  innere  Medicin  in  1897. 
In  these  three  cases  the  author  was  able  to  grow  a  culture  of  the  bac- 
terium coli  from  the  urine.  He  believes  the  bacterium  coli  to  be  the  true 
etiological  factor  in  this  disease.  In  these  three  cases  there  were  marked 
gastroenteric  disturbances;  in  two  cases,  membranous  enteritis  and  obstinate 
constipation.  In  my  case  here  reported  there  was  severe  constipation  requir- 
ing constant  treatment. 

Baginsky  further  maintains  that  the  bacterium  coli  can  enter  the 
kidneys  through:  first,  the  circulation  of  the  blood;  second,  the  lymph 
channels;  third,  the  urethra. 

Escherich,^  Finkelstein,^  and  Trumpp^  have  reported  a  series  of  cases 
in  which  cystitis  was  found  associated  with  intestinal  affections.  Baginsky 
reports  two  cases  of  pyelonephritis  which  could  be  attributed  to  the  method 
of  using  gymnastics  during  orthopsedic  treatment  for  the  correction  of  con- 
genital dislocation  of  the  hip-joint.  In  connection  with  the  exercises  a 
direct  invasion  of  the  bacterium  coli  from  the  urethra  to  the  bladder  could 
be  traced.  Other  authors,  as  Posner,  believe  that  external  influences  have 
no  bearing  on  the  etiology,  and  that  the  infection  takes  place  from  within 
the  body.  It  is  a  well-known  fact  that  gonorrhoeal  vulvo-vaginitis,  espe- 
cially when  it  occurs  in  little  girls,  can  cause  either  pyelitis  or  pyelone- 
phritis. This  is  termed  the  ascending  variety.  Chronic  occlusion  of  the 
ureter  may  be  followed  by  a  pure  pyelonephritis,  without  preceding  cystitis, 
when  the  exciting  agents  of  inflammation,  which  are  present  in  the  cir- 
culating blood,  are  eliminated  through  the  kidneys  and  collect  in  the  stag- 
nating urine  in  the  pelvis  of  the  kidneys.  Experimentally  this  disease  can 
be  produced  in  rabbits  by  ligating  the  ureter  and  injecting  either  bacterium 
coli  or  pyogenic  cocci  directly  into  the  pelvis  of  the  kidney  or  into  the 
veins. 


^Mittheil.  d.  Vereins  der  Aerzte  in  Steiermark,  1894. 

^  Finkelstein,  Jahrbuch  f.  Kinderheilkunde,  Band  xliii,  page  148. 

^  Trumpp,  Ibid.,  Band  xliv,  page  249. 


J'^•|•:lJ'^ls. 


377 


Pathology. — Increased  pressure  in  the  tubules  from  obstruction  to  the 
escape  ol'  mine;  reflex  irritation  of  tlie  kidney;  the  presence  of  septic 
matter  in  the;  pelvis  of  tlie  Ividney  and  ])()ssibly  in  tlie  lower  parts  of  the 
tubules.  Most  frequently  these  three  causes  act,  in  succession' and  in  the 
above  order,  in  the  same  case.  As  a  rule,  when  acting  singl_y,  increased  pres- 
sure from  ol;structinn  wW]  produce  liych'oneplirosis;  reflex  irritation  will 
excite  one  ol  the  transient  or  congestive  types  of  urinary  fever;  and  septic 
matter  in  the  pelvis  of  the  kidney  will  cause  acute  or  suppurative  pyelone- 
phritis. Increased  urinary  pressure  alone  often  j^i'^duces  chronic  inter- 
stitial nephritis  as  Avell  as  sacculation  and  dilatation  of  the  kidney;  but  it 
rarely,  if  ever,  causes  acute  or  subacute  interstitial  nephritis.     Deconipo- 


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sition  of  urine  in  the  bladder  or  pelvis  of  the  kidney  may  produce  suppura- 
tive changes  in  the  kidne3^s.  If  the  dilatation  of  the  kidney  is  not  compli- 
cated by  suppurative  pyelitis  hydronephrosis  results.  If  it  is  so  compli- 
cated, loyonephrosis  is  jDroduced.  Klebs  and  others  believe  that  bacteria  have 
migrated  to  the  pelvis  and  calices  of  the  kidney,  there  to  produce  their 
destructive  changes,  hence  the  names  of  parasitic  nephritis  and  pyelo- 
nephritis as  proposed  by  Klebs. 

Lindsay  Steven  in  a  thesis  on  the  pathology  of  the  suppurative  inflam- 
mations of  the  kidney,  published  in  the  Glasgow  Medical  Journal,  Septem- 
ber, 1884,  corroborates  Klebs's  view  and  expresses  a  decided  opinion  that 
micro-organisms  are  at  the  root  of  the  infection,  and  cause  the  formation 
of  multiple  renal  abscesses  consequent  on  diseases  of  the  lower  urinary 
passages.  He,  however,  considers  that  there  are  two  ways  "whereby  the  par- 
ticular virus  gains  access  to  the  kidney  and  sets  up  suppuration  in  many 
different  points,  namely:  first,  by  means  of  the  uriniferous  tubules,  and 
second,  by  means  of  the  lymphatics  of  the  ureter  and  kidney. 


378  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

Steven  shows  that  the  lymphatics,  quite  independently  of  any  other 
■channel,  may  form  the  pathway  of  the  virus  from  the  bladder  to  the  kidney. 
He  admits  that  the  two  ways  may  be  more  or  less  combined  in  many  cases ; 
so  that  multiple  miliar}^  abscesses  may  originate  in  the  same  kidney,  partly 
by  the  invasion  of  inicrococci  along  the  ureter  and  uriniferous  tubules,  and 
partly  by  their  inroad  along  the  lymphatic  tracts  of  the  kidney. 

Traube  and  others  who  do  not  think  that  the  bacteria  themselves 
excite  the  inflammation,  consider  that  these  organisms  cause  the  decom- 
position of  urea  into  carbonate  of  ammonia  and  that  this  in  turn  excites 
the  inflammation  of  the  mucous  membrane  of  the  kidney. 

Prognosis. — The  prognosis  is  grave  and  depends  on  the  toxin  caused 
by  the  presence  of  the  pus.  The  outcome  of  the  case  depends  on  the  dis- 
appearance of  the  pus  in  the  urine,  which  must  be  watched  for  at  times. 

Treatment. — A  child  suffering  with  pyelitis  should  be  put  to  bed  in 
a  cool  room  having  plenty  of  fresh  air  and  sunlight. 

Dietetic  treatment  such  as  milk  with  some  alkaline  water  is  useful. 
ISTo  solid  food  should  be  permitted.  Whey,  soups,  broths,  and  fruit  juices 
may  be  given.  Oranges  and  lemons,  owing  to  their  diuretic  effect,  are 
valuable.  The  internal  use  of  Eoncegno  water  or  Wildungen  water  is  also 
recommended  for  its  diuretic  effect. 

Diuretin,  in  2  to  10-grain  doses  three  times  a  day,  is  sometimes  useful. 
Urotropin  is  a  very  valuable  drug  and  serves  both  as  a  diuretic  and  as  an 
internal  antiseptic. 

The   Bladder. 

The  bladder  takes  up  almost  all  of  the  lower  portion  of  the  abdomen, 
as  it  is  capable  of  marked  distention  when  filled.  To  make  proper  physical 
examination  the  bladder  should  be  emptied  by  catheter. 

Eotch  refers  to  a  distinguished  laparotomist  who  did  not  empty  the 
bladder  of  a  child  before  operating  for  an  appendicitis ;  on  opening  the 
abdominal  cavity  he  cut  directly  through  the  walls  of  the  bladder.  The 
urine  flowing  out  reminded  him  of  his  failure  to  appreciate  the  fact  that 
in  early  life  the  bladder  is  essentially  an  abdominal  organ. 


Ectopia  Yesicje   Congenitalis    (Extroversion  of  the  Bladder: 
Exstrophy  of  the  Bladder). 

This  anatomical  peculiarity  is  due  to  deficient  closure  of  the  neutral 
laminas  causing  this  hiatus  of  the  abdominal  wall  in  some  cases.  "The 
lower  part  of  the  abdominal  wall,  from  the  umbilicus  or  its  neighborhood 
downward,  may  fail  to  close,  and,  coupled  with  this,  there  may  be  deficiency 
of  the  anterior  wall  of  the  bladder."     This  constitutes  extroversion,  some- 


KCTOIMA    VESIC-E   CONGENITALIS. 


379 


times  called  exstrophy  of  the  bladder.  The  ureters  are  plainly  visible  and 
the  urine  dribbles  continuously.  'J'he  child  is  constantly  wet  and  excoriated 
from  the  moisture  and  its  irritation.  'J'he  urine  is  passed  in  distinct  jets 
or  streams,  and  is  especially  noticeable  when  the  child  cries  or  strains. 

The  following  case  was  presented  by  me  to  the  children's  clinic  of  the 
New  York  Post-Gradaate  Medical  School  and  Hospital.^ 

A  female  infant,  1  year  old,  was  seen  by  me.  She  was  breast-fed  and  well- 
nonrished.  Soon  after  birth  the  mother  noticed  a  constant  dribljling  of  urine  and 
attention  Avas  directed  to  a  swelling  situated  in  the  region  of  the  umbilicus.     The 


Fig.    114.— Exstrophy   of   the   Bladder,   and   Prolapse   of   Anus.    (Original.) 


diagnosis  of  exstrophy  of  the  bladder  was  made.  A  bland  ointment  was  prescribed 
to  relieve  the  excoriation  from  the  constant  dribbling  of  urine.  As  this  case 
required  a  jilastic  operation  it  was  referred  to  Dr.  Carl  Beck,  at  the  St.  Mark's 
Hospital,  for  surgical  treatment. 


1  This  case  was  also  presented  by  me  at  the  Scientific  Society  of  German  Phy- 
sicians held  at  the  residence  of  Dr.  A.  Jacobi  about  ten  years  ago. 


380  DISEASES  OF  THE   KIDNEY  AND  BLADDER. 

A  child  in  this  condition  should  not  be  operated  npon  until  3  or  4 
years  of  age. 

Indicandria. 

A  trace  of  indican  is  found  in  the  urine  in  health.  A  very  strong 
indican  reaction  should  always  be  regarded  as  abnormal  and  hence  it  is 
pathological.  As  indican  is  derived  from  indol  it  signifies  a  product  of 
decomposition  and  denotes  putrefaction  of  the  proteins.  It  has  also  been 
found  in  empyema  and  in  extensive  suppurative  processes  where  putrefac- 
tion abounds.  Stagnant  faeces,  constipation,  chronic  intestinal  indigestion, 
and  some  forms  of  putrefactive  diarrhoea  will  give  a  strong  indican  reaction. 
Herter  has  reported  the  presence  of  indican  in  the  virine  in  cases  of 
epilepsy  at  the  time  of  the  seizures.  In  the  early  stages  of  typhoid  fever, 
when  the  diagnosis  is  doubtful,  the  presence  of  a  diazo  reaction  and  the 
absence  of  indicanuria  is  a  valuable  aid  in  establishing  the  diagnosis. 

Eliminative  treatment  such  as  cleansing  the  gastro-intestinal  tract, 
besides  reducing  the  amount  of  meat  and  eggs,  will  relieve  an  excess  of 
indican  (see  articles  on  "Intestinal  Indigestion"). 

Acetonemia. 

This  condition  is  caused  by  the  faulty  assimilation  of  food.  It  is 
usually  found  in  children  over  2  years  of  age,  and  occurs  most  frequently 
in  children  between  the  ages  of  5  and  12  years. 

Symptoms. — Fever  ranging  between  102°  and  105°  is  usually  present. 
There  is  a  correspondingly  increased  pulse  rate.  Some  cases  show  nausea 
or  singultus,  anorexia,  and  intense  thirst.  Some  complain  of  headache,  and 
vomit.  The  characteristic  sweet  vinegar  odor,  "acetone  breath,"  is  present. 
The  urine  contains  acetone  and  usually  indican.  The  eyes  appear  sunken. 
The  child  presents  a  typhoidal  appearance. 

Treatment. — The  diet  must  be  restricted  for  twenty-four  or  forty-eight 
hours  to  skimmed  milk  or  weak  tea,  strained  soups,  and  fruit  juices. 

Large  doses  of  soda  bicarb,  are  indicated.  In  severe  forms  of  acetonuria 
typhoidal  symptoms  may  be  present,  and,  if  so,  an  intravenous  injection 
of  soda  bicarb,  is  indicated. 

The  prognosis,  as  a  rule,  depends  on  the  restriction  of  the  diet,  and  on 
the  amount  of  soda  bicarb,  given  to  counteract  the  effect  of  this  poison.  The 
injection  of  a  10  per  cent,  soda  bicarb,  solution  into  the  colon  will  also  aid 
in  modifying  this  condition. 

Acetonuria. — Diacetonuria. 

We  are  indebted  to  Baginsky  for  a  careful  study  of  this  condition.  He 
found  that  it  was  present  in  children  during  epileptic  attacks.     It  is  also 


PYURIA.  381 

found  during  the  height  of  fever.    He  does  not  believe  that  acetonuria  bears 
any  relation  to  the  nervous  symptoms  which  accompany  fever. 

Diacetonuria  is  very  common  during  high  fever.  It  is  more  frequently 
present  than  acetonuria.  Binet,  quoted  by  Holt,  found  diacetic  acid  in 
G9  out  of  150  examinations  in  febrile  diseases,  chiefly  in  scarlet  fever, 
measles,  and  pneumonia. 

Pyuria. 

"When  pus  is  found  in  the  urine,  it  gives  a  reaction  like  albumin,  namely, 
coagulates  on  boiling.  Pus  cells,  however,  can  be  seen  only  by  placing  a 
drop  under  the  microscope,  using  low  power.  While  pus  usually  indicates 
pyelitis  or  pyelonephritis,  it  may  exude  from  the  ureters,  the  bladder,  the 
urethra,  or  the  vagina. 

Tubercular  or  suppurative  conditions  affecting  the  spine  associated  with 
caries  of  the  spinal  vertebrge  may  drain  into  the  urinary  tract.  It  is  impor- 
tant, therefore,  to  locate  the  cause  before  treatment  is  commenced. 

Pus  from  the  bladder  is  always  mixed  with  mucus.  It  may  be  acid  or 
alkaline  in  reaction.  The  urine  containing  pus  due  to  pyelitis  has  an  acid 
reaction.  If  the  child  is  old  enough,  a  cystoscopic  examination  should  l)e 
made.  This  will  aid  in  excluding  the  bladder  and  the  ureters  as  a  possible 
source  of  the  pus. 

Treatment. — ^Demulcent  drinks,  alkaline  waters,  such  as  the  Wildungen 
water,  have  a  mild,  diuretic  effect.  Salol  and  urotropin  are  the  best  drugs 
in  doses  of  2  to  5  grains  three  times  a  day.  Milk,  cereals,  and  fruits  should 
be  ordered ;  meat  and  eggs  prohibited. 

Lordotic  Albuminuria  (Orthostatic  Albuminuria). 

Heubner  has  directed  attention  to  the  presence  of  albumin  in  the 
urine  when  children  are  standing  erect.  The  albumin  disappears  wlien  the 
child  assumes  a  horizontal  position ;  hence  albumin  will  be  present  by  day, 
and  will  disappear  in  the  urine  voided  at  night. 

Jehle,  of  Vienna,  in  his  monograph  published  in  1909,  has  studied  this 
question  more  closely,  and  finds  a  different  cause  for  the  presence  of  the 
albumin  in  the  urine.  Pie  finds  that  when  lordosis  is  present,  and  in  con- 
sequence the  lumbar  vertebrae  offend  the  kidneys  by  displacement  or  pres- 
sure, albumin  will  at  once  appear  in  the  urine.  That  this  is  no  theory 
he  shows  by  producing  an  artificial  lordosis.  When  in  the  dorsal  position 
albumin  will  be  found  in  the  urine  and  disappear  wlien  such  pressure  is 
removed.  This  presence  of  albumin  is  found  in  normal  kidneys  in  which 
no  previous  scarlatinal  or  other  forms  of  nephritis  have  existed.  It  is, 
therefore,  a  mechanical  type  of  albuminuria  which  can  be  made  to  appear 
during  the  lordosis  and  to  disappear  when  the  lordosis  is  corrected. 


582  DISEASES  OF  THE  KIDNEY  AXD   BLADDER. 


ILematuria  (Bloody  Urine). 

IlaMiiatuiia  is  known  by  the  presence  of  red  blood-cells  in  the  -urine.  It 
may  be  due  to  local  irritation  or  to  systemic  disease.  It  is  therefore  fre- 
quently met  with  during  the  course  of  a  severe  attack  of  acute  nephritis 
complicating  scarlet  fever.  A  case  of  this  kind  is  reported  in  the  chapter 
on  "Scarlet  Fever."  I  have  frequently  seen  hgematuria  during  the  course 
of  the  hemorrhagic  form  of  diphtheria  while  on  duty  at  the  Willard 
Parker  Hospital.     I  have  also  seen  hasmaturia  in  scurvy. 

It  is  important  to  remember  that  irritation  caused  by.  a  calculus  in 
the  kidney,  the  ureter,  or  the  bladder  may  give  rise  to  bloody  urine.  Direct 
injury  to  the  kidney  or  bladder,  or  a  tumor  in  the' bladder,  may  cause 
bloody  urine. 

Tlie  ge?ieral  causes  frequently  met  with  arc  hsemorrhagic  diseases  of 
the  new-born;  the  blood  dyscrasias,  such  as  scurvy,  purpura,  and  hemo- 
philia; and  infectious  diseases,  particularly  malaria,  typhoid,  variola,  scar- 
let fever,  and  influenza.  In  most  of  these  cases  the  amount  of  blood  passed 
is  small.  When  it  is  large  it  may  appear  in  the  urine  as  clear  blood  or  as 
clots,  or  it  may  impart  simply  a  reddish  or  smoky  color 'to  the  urine.  The 
color,  however,  is  not  a  reliable  guide;  the  best  of  all  is  the  microscopic 
examination.     For  a  simple  chemical  test  guaiacum  may  be  used   (Holt). 

It  is  a  difficult  matter  to  discover  the  source  of  blood  in  some  cases, 
although  large  haemorrhage  is  more  apt  to  result  from  the  kidneys  than 
from  the  bladder.  To  differentiate  we  must  rely  on  the  presence  of  casts 
from  the  renal  tubules;  thus  we  can  satisfy  ourselves  of  the  renal  origin 
of  the  hemorrhage. 

The  prognosis  depends  on  the  amount  of  hemorrhage  and  the  general 
condition  of  the  child.  It  should  always  be  regarded  as  a  bad  symptom,, 
although  not  necessarily  fatal. 

Treatment. — The  application  of  an  ice-bag  or  dry  cups  over  the  region 
of  the  kidneys,  rest  in  bed,  Squibb's  ergot,  gallic  acid,  3  to  10  grains, 
repeated  every  three  or  four  hours,  or  the  fluid  extract  of  hydrastis  cana- 
densis, in  3-  to  10-  drop  doses,  for  a  child  2  years  old,  repeated  every  three 
or  four  hours,  will  sometimes  do  good. 

The  food  is  best  given  either  cool  or  very  cold.  If  the  child  is  old 
enough,  small  pieces  of  cracked  ice  or  ice  cream  may  be  given  until  the 
blood  disappears. 

HEMOGLOBINURIA. 

Instead  of  blood  cells  in  the  urine  this  condition  manifests  itself  by 
the  presence  of  hlood  pigment  in  the  urine.  Sometimes  the  urine  is 
blackish.  Albumin  may  frequently  be  found  associated  with  hemoglobin. 
The  pathology  of  this  condition  is  at  present  unknown.     It  is  very  easy  to- 


DIABETES  INSIPIDUS.  383 

recognize  the  pigment  under  the  microscope.  It  can  also  be  noted  by 
Heller's  test.     The  most  positive  method  of  diagnosis  is  the  spectroscope. 

Not  infrequently  this  condition  is  met  with  in  the  infectious  diseases, 
which  is  evidently  due  to  the  effect  of  the  toxins  generated  by  the  specific 
micro-organisms  causing  these  diseases.  When  an  irritant  poison,  such  as 
carbolic  acid,  is  swallowed,  this  condition  is  encountered  and  recognized, 
clinically,  by  the  familiar  term  "smoky  urine." 

Paroxysmal  haemoglobinuria  is  occasionally  met  with  in  childhood. 
It  is  usually  associated  with  syphilis.    Other  cases  have  been  reported.^ 

Glycosuria. 

The  appearance  of  sugar  in  the  urine  is  not  necessarily  pathological. 
Grosz  published  a  series  of  investigations  dealing  with  this  condition.  He 
found  that  glycosuria  occurs  in  nursing  infants  who  have  either  functional 
or  inflammatory  disturbances  of  digestion.  He  did  not  see  it  in  perfectly 
healthy  nursing  infants.  The  sugar  found  in  the  urine  reacts  to  Fehling's 
test;  it  does  not  respond  to  the  fermentation  test.  The  polariscope  shows 
that  it  has  the  power  of  dextro-rotation,  so  that  the  sugar  present  is  pos- 
sibly milk  sugar  or  one  of  its  derivatives. 

Artificial  glycosuria  can  be  produced  by  administering  a  large  quan- 
tity of  milk  sugar  in  the  food;  hence  it  may  be  presumed  that  the  sugar 
excreted  in  the  urine  is  simply  the  excess  of  what  could  not  be  absorbed  in 
the  system. 

Glj'cosuria  was  frequently  noted  by  me  in  the  urine  of  children  fed 
exclusively  on  Nestle's  food.  When  this  form  of  feeding  was  discontinued, 
the  glycosuria  disappeared.  These  cases  could  therefore  be  classified  under 
the  head  of  dietetic  glycosuria. 

Diabetes  Insipidus   (Polyuria). 

This  is  a  very  rare  condition  in  children.  Its  etiology  is  obscure, 
although  males  are  more  frequently  attacked  than  females.  Little  is  known 
of  its  origin  excepting  that  traumatism  involving  the  brain  has  been  known 
to  be  followed  by  diabetes  insipidus. 

The  pathology  of  this  disease  is  unknown.  It  is  supposed  to  be  a 
neurosis,  but  whether  the  lesion  is  near  the  fourth  ventricle,  or  whether  its 
seat  is  in  the  renal  nerves,  has  not  yet  been  determined. 

Symptoms. — Excessive  thirst  and  an  excess  of  urine  constitute  the  main 
symptoms.  From  five  to  ten  pints  or  even  more  may  be  passed  in  twenty- 
four  hours.  The  urine  looks  like  water  and  has  a  specific  gravity  from 
1001  to  1005.  In  some  cases  mosite  (muscle  sugar)  has  been  found  (Holt). 
Albumin  and  grape  sugar  are  not  found.     Urea  is  excreted  in  large  quan- 


*  Archives  of  Pediatrics. 


384  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

titles,  whereas  uric  acid  is  not.  Eestlessness  by  day,  headache,  insomnia, 
and  marked  irritability  are  the  chief  symptoms.  Unilateral  flushes  of  the 
face  and  one  ear  and  similar  vasomotor  disturbances  are  present.  There 
is  an  absence  of  perspiration.  The  skin  is  dry.  Development  is  retarded, 
-especially  growth'.  The  appetite  remains  good.  The  temperature  may'^be 
subnormal. 

Prognosis. — The  disease  has  been  known  to  last  years.  Some  cases 
recover  spontaneously.  As  a  rule,  it  is  wise  to  give  a  guarded  prognosis. 
Cases  of  diabetes  insipidus  are  very  susceptible  to  other  diseases  and  usually 
die  from  some  complication. 

Treatment. — A  very  nutritious  diet  consisting  of  milk,  meat,  eggs,  and 
fruit  with  some  restriction  as  to  the  quantity  of  liquid  should  be  made. 
Eestoratives  such  as  Fowler's  solution,  iron,  and  codliver-oil  will  sometimes 
•do  good.  When  marked  nervous  symptoms  exist,  then  atropine,  Dover's 
powder,  belladonna  and  the  bromides  may  be  tried.  Change  of  air  such  as 
an  ocean  voyage  or  mountain  air  may  be  of  benefit. 

Diabetes  Mellitds. 

The  pathological  studies  of  Weiehselbaum  and  Opie  at  the  Rockefeller 
Institute  have  established  the  relationship  which  the  pancreas  and  more 
especially  the  islands  of  Langerhans  bear  to  this  disease.  The  internal 
secretions,  notably  the  adrenal  system,  play  an  important  part  in  influencing 
the  metabolism  of  fat,  casein,  and  the  carbohydrates.  Congenital  syphilis 
is  sometimes  responsible  for  diabetes.  Predisposition  must  also  be  con- 
sidered when  the  tendency  toward  family  diabetes  is  noted. 

Saundby,  in  a  report  of  2011  cases  of  diabetes  in  adults  and  children, 
found  only  15  occurring  in  .children  under  5  years  of  age,  and  58  in  children 
under  10  years.    The  extreme  rarity  of  diabetes  is  recognized. 

Acidosis  is  generally  considered  to  be  a  result  of  the  diabetic  condition. 
It  is  probable,  however,  that  an  acid  condition  may  have  much  to  do  with 
the  causation  of  diabetes.  This  condition  has  been  termed  "acidsemia" — 
hyperacidity  or,  rather,  hypoalkalinity  of  the  blood.  It  has  no  connection 
with  the  term  "acidosis,"  this  latter  being  considered  as  occurring  only 
when  oxybutyric  acid  or  its  congeners  (acetone  or  diacetic  acid)  are  present. 
Acidsemia  is  an  extremely  common,  everyday  occurrence  and,  unfortunately, 
it  is  all  too  often  overlooked  in  routine  work.  A  one-sided  dietary  in  which 
meats,  fish,  fats,  etc.,  predominate  produces  organic  acids,  whereas  a  dietary 
of  cereals,  milk,  vegetables,  and  fruits  tends  to  maintain  the  normal  alka- 
line condition  by  reason  of  the  food-salts  they  contain  in  their  best  and 
most  assimilable  form. 

According  to  the  theory  of  Naunyn  and  his  school,  the  diminution  of 
the  alkalinity  of  the  blood  and  tissues  is  at  the  root  of  the  essential  nature 


COLICYSTITIS.  385 

of  the  diabetic  intoxication.  This  they  regard  as  a  true  acid  poisoning,  the 
culminating  point  of  which  is  eventually  diabetic  coma. 

The  carbohydrates  form  about  one-half  the  diet  of  a  growing  child. 
The  adult  diet  contains  about  one-third  carbohydrates.  The  liver,  pan- 
creas, and  intestinal  glands  of  the  child  assimilate  much  more  carbohydrate 
than  those  of  the  adult. 

Symptoms. — The  most  prominent  symptoms  noticeable  are  irritability 
and  general  indisposition,  increased  thirst  with  associated  polyuria.  Some- 
times the  extreme  thirst  and  polyuria  are  wanting.  Fever  seldom  occurs. 
Tenderness  is  sometimes  present  over  the  region  of  the  pancreas.  The 
knee-jerks  are  sometimes  entirely  absent  during  the  height  of  the  disease*. 
When  a  tendency  toward  slow  healing  is  noted  in  surgical  conditions,  then 
we  should  suspect  glycosuria.  Albumin  when  present  is  a  serious  factor. 
Wegeli  found  that  in  13  cases  ending  fatally  albumin  was  present.  Acetone 
and  diacetic  acid  are  very  frequently  found  in  infantile  glycosuria. 

The  urine  may  vary  between  1%  and  10  pints  in  twenty-four  hours. 
The  specific  gravity  varies  between  1.008  and  1.050.  The  quantity  of 
sugar  varies  between  1  and  6  per  cent.,  depending  on  the  time  of  the  day 
and  the  type  of  food  ingested.  Albumin  when  present  is  usually  a  serious 
complication. 

Prognosis. — The  prognosis  is  always  grave.  When  the  urine  contains 
diacetic  and  oxybutyric  acids  the  condition  is  more  serious  than  when  the 
urine  contains  sugar  alone. 

Eoughly  stated,  the  duration  of  the  disease  may  be  about  six  months, 
although  some  children  linger  for  years. 

Treatment. — The  body  demands  carbohydrates;  hence  the  treatment 
should  aim  to  secure  a  tolerance  for  carbohydrate  food.  Milk,  oatmeal  oc- 
casionally, cabbage,  lettuce,  asparagus,  vegetable  soups  of  tomato  or  spinach, 
eggs,  chicken,  beef,  and  nuts,  chiefly  almonds,  should  form  the  bulk  of  the 
diet.    Honey  contains  levulose  and  is  sometimes  well  borne. 

A  school  child  should  be  removed  from  school  and  sent  to  the  country. 
The  method  of  living  should  be  entirely  changed.  When  acidosis  is  present, 
10  to  15  grains  of  bicarbonate  of  soda  may  be  given  three  or  four  times  a 
day.  Atropine,  Vooo  to  ^/n,o  grain  three  times  a  da}^,  and  methyl  bromide, 
Vi2o  grain,  should  be  tried. 

COLICTSTITIS. 

We  are  chiefly  indebted  to  Escherich  for  calling  our  attention  to  this 
condition. 

Bacteriology  and  Pathology. — The  bacterium  coli  commune  gives  rise 
to  this  condition.  The  bacteria  can  migrate  through  the  female  urethra 
and  set  up  a  cystitis.    When  the  intestinal  mucous  membrane  is  not  intact, 


386  DISEASES  OF  THE  KIDNEY  AND  BLADDER. 

as,  for  example,  in  catarrhal  enteritis,  these  bacteria  can  enter  the  bladder 
by  migrating  through  the  intestinal  mucous  membrane. 

Symptoms. — There  is  fever  and  irritability  of  the  bladder  shown  by 
tenesmus.  The  urine  contains  pus,  sometimes  traces  of  albumin,  and  has  a 
very  foul  odor.  As  a  rule,  the  urine  is  milky  or  cloudy,  or  it  may  be  dark 
in  color.  In  some  cases  there  may  be  vomiting  and  headache  associated  with 
pains  in  the  bladder  and  in  the  back. 

Prognosis. — The  prognosis  is  good. 

Treatment. — Internally,  3  to  5  grains  of  urotropin,  several  times  a 
day,  or  oleum  gaultheria,  1  to  3  drops,  three  times  a  day,  or  salol,  3-  to 
h-  grain  doses,  three  times  a  day,  may  be  given. 

Locally. — The  bladder  should  be  washed  with  a  double  current  catheter. 
A  weak  permanganate  of  potash  solution  should  be  used,  3  or  4  ounces 
being  injected  at  one  time;  this  should  be  continued  until  several  pints 
have  been  used.  In  some  cases  irrigations  of  a  bichloride  of  mercury  solu- 
tion, 1  to  4000,  repeated  several  times  a  day,  may  be  useful. 

Ueethral  Calculi  (Vesical  Calculi;  Stone  in  the  Bladdek). 

This  condition  is  extremely  rare  in  infancy.  It  is  not  so  rare  in  chil- 
dren after  the  third  year,  owing  to  their  solid  diet.  Stone  in  the  bladder 
is  usually  composed  of  uric  acid,  and  is  often  the  result  of  uric  acid  in- 
farction in  the  kidney.  In  this  condition  calculi  pass  from  the  pelvis  of  the 
kidney  through  the  ureters  and,  lodge  in  the  bladder. 

Sjrmptoms. — While  urinating  there  will  be  a  sudden  cessation  of  the 
flow  of  urine.  Pain  either  in  the  penis  or  in  the  perineum  is  sometimes 
described.  As  has  been  described  (in  the  articles  on  ''^Cystitis"),  whenever 
severe  tenesmus  exists,' causing  prolapse  of  the  rectum  without  definite  in- 
testinal trouble,  we  should  suspect  trouble  in  the  bladder.  Incontinence  of 
urine  is  sometimes  present. 

Diagnosis. — If  the  child  is  old  enough  a  diagnosis  can  sometimes  be 
made  by  inserting  one  finger  into  the  rectum  and  pressing  over  the  bladder 
in  the  abdomen  (bimanual  examinatioli) .  Although  this  method  of  bi- 
manual palpation  is  frequently  valuable,  it  sometimes  gives  negative  re- 
sults. The  surest  method  is  to  explore  the  bladder  with  a  sound.  In  very 
sensitive  children  cocaine  may  be  injected  into  the  urethra  before  the  sound 
is  passed.  In  exceptional  cases,  only  with  the  aid  of  an  ansesthetic,  can 
a  positive  diagnosis  be  made. 

Treatment. — Such  cases  should  be  treated  by  the  surgeon,  although  an 
attempt  at.  crushing  the  stone  might  be  made.  The  radical  operation  of 
suprapubic  lithotomy  may  be  necessary. 

Very  large  calculi  have  been  seen  by  me  in  the  Stephanie  Children's 
Hospital,  in  Buda-Pest.    Professor  Bokai  told  me  that  from  certain  districts 


CHRONIC  CYSTITIS.  387 

in  Hungary  they  receive  many  cases  of  large  vesical  and  urethral  calculi. 
It  is  therefore  quite  evident  that  the  calculi  are  intimately  associated  with 
the  geographical  conditions  favoring  the  same. 

Acute  Cystitis. 

This  condition  is  seldom  seen  in  children. 

Etiology. — It  is  most  usually  due  to  the  invasion  of  pathogenic  bac- 
teria, such  as  the  bacterium  coli  and  the  gonococcus. 

It  is  most  frequently  the  result  of  an  extension  of  an  infection  from 
the  external  genitals  through  the  urethra  into  the  bladder,  so  that  blenor- 
rhoea  in  children  may  be  an  exciting  cause  of  acute  cystitis.  It  has  also 
been  known  to  arise  from  typhoid  bacilli  eliminated  through  the  kidneys 
by  the  urine. 

Stone  in  the  bladder  and  intestinal  irritants,  such  as  turpentine  or 
copaiba,  have  been  known  to  cause  cystitis. 

Females  are  more  prone  to  this  affection  than  males. 

Symptoms. — ^Very  frequent  desire  to  urinate,  accompanied  by  pain  on 
urination,  is  the  principal  symptom.  The  urine  has  a  reddish  color,  but 
later  in  the  disease  has  a  light  color.  Its  specific  gravity  is  high.  The 
reaction  of  the  urine  is  alkaline.  On  standing  there  is  a  thick  sediment 
consisting  of  mucus,  pus,  and  blood.  Microscopically,  there  are  pus  cor- 
puscles, squamous  epithelium,  and  blood-corpuscles.  In  females  it  is  neces- 
sary to  use  a  catheter  in  drawing  off  the  urine  to  obtain  a  specimen  for 
examination,  as  the  epithelium  of  the  bladder  and  the  vagina  are  strikingly 
similar. 

Prognosis. — ^This  is  invariably  good. 

Treatment. — Bladder  washing  with  mild  antiseptic  solutions,  such  as 
a  1  per  cent,  boric  acid  or  bichloride,  1  to  5000,  or  a  weak  permanganate 
of  potash  solution,  is  useful  in  some  cases.  Alkaline  waters,  such  as  the 
White  Eock,  Lithia,  or  Appollinaris,  in  large  quantities  should  be  given. 

Internally  the  diet  should  be  regulated  so  that  the  child  receives  milk 
and  Seltzer,  thin  soups  and  broths,  fruit  and  fruit  juices.  Meat  and  all 
spices  must  be  avoided.    Only  bland  articles  may  be  permitted. 

Drug  Treatment. — ^Urotropin,  in  doses  of  5  to  10  grains,  several  times 
a  day,  is  very  beneficial,  or  Dover's  powder,  1  or  2  grains,  several  times  a 
day,  will  do  good.  In  very  high  fever  an  ice-bag  can  be  applied  over  the 
bladder. 

I 

Chronic  Cystitis. 

This  condition  is  usually  associated  with  a  malignant  growth  in  the 
bladder,  such  as  a  tumor,  or  frequently  by  stone  in  the  bladder.  It  may 
also  be  due  to  a  general  tuberculosis  with  special  local  manifestations  in 


388  DISEASES   OF  THE  KIDXEY  AND  BLADDER. 

the  bladder.  Tlie  composition  of  calculus  is  mainly  uric  acid,  with  large 
quantities  of  phosphates  from  the  alkaline  urine. 

Symptoms. — From  the  constant  dribbling  of  urine  the  child  will  have 
an  offensive  urine  smell  resembling  ammonia  about  him. 

There  is  an  irritation  around  the  external  genitals,  due  to  excoriation 
from  the  moisture.  If  stone  is  the  cause  of  this  condition  the  urine  will 
be  interrupted  while  passing  and  the  child  will  complain  of  pain.  The 
pain  is  difficult  to  localize,  although  it  is  described  as  being  at  the  end  of 
the  penis.  Girls  will  localize  the  pain  at  the  meatus.  From  severe  tenesmus 
there  may  be  prolapse  of  the  rectum. 

The  urine  resembles  the  urine  of  an  acute  cystitis.  Tubercle  bacilli  are 
found  in  bladder  tuberculosis. 

Prognosis. — This  depends  upon  the  condition  of  the  child  and  on  the 
cause  of  this  affection.  A  cautious  prognosis  is  necessary  in  tuberculous 
affection,  or  if  a  tumor  exists. 

Treatment. — If  a  stone  is  present  the  treatment  is  surgical.  Urot- 
ropin  and  salol  are  very  valuable,  and  I  have  seen  permanent  benefit  from 
their  use. 

IJ  Sodium   sulpho-carbolate    25  grains 

Sig. :  Divide  into  5  powders.  One  powder  every  three  hours  in  an  alkaline 
water  is  also  beneficial  in  some  cases. 

Bladder  washing  and  the  diet  as  described  in  the  article  on  "Acute 
Cystitis"  should  be  employed  in  chronic  cases. 

When  there  is  a  general  atony  of  the  body,  then  this  condition  will  fre- 
quently result  in  the  weakening  of  the  sphincter  vesicse  muscle  or  in  the 
spasm  of  the  detrusor  urinse  muscle.  Other  conditions  causing  enuresis 
are  lithiasis  vesicalis,  and  where  stones  are  suspected  the  bladder  must  he 
very  cautiously  inspected. 

Children  that  convalesce  from  a  severe  form  of  disease,  such  as  typhoid 
fever  or  any  long-existing  febrile  disorders,  will  usually  have  enuresis  as  a 
result  of  a  general  breaking  down  of  the  body  wherein  the  muscles  lose 
their  tone. 

Other  conditions  causing  irritation  may  be  enumerated  as  congenital 
phimosis  or  adhesions  of  the  prepuce,  strictures  of  the  urethra;  also  irrita- 
tions from  worms,  such  as  ascarides,  commonly  kno^vn  as  pin-worms;  fis- 
sures of  the  anus;  frequently  also  in  older  children  masturbation  and 
vulvitis  may  be  considered  as  possible  causes  of  this  condition.  (Eead 
article  on  "Lithuria.'^) 

Calcareous  deposits  in  the  kidney  or  stone  in  the  bladder,  the  over- 
loading of  the  urine  with  lithates  or  phosphates,  have  frequently  caused 
abnormal  irritations  resulting  in  enuresis. 


ENURESIS.  389 

Enuresis. 

An  involuntary  emptying  of  the  bladder  during  the  day  is  known  as 
enuresis  diuma.  When  this  condition  exists  at  night  it  is  known  as  enu- 
resis nocturna. 

Causes. —  (a)  Organic;  (&)  functional.  ^ 

Organic  Causes. — Any  inflammatory  condition  involving  the  urethra 
or  bladder,  or  diseases  of*  the  brain  or  spinal  cord,  frequently  cause  this 
condition. 

Thiemich^  considers  this  condition,  when  occurring  in  a  child  who 
has  been  clean  for  months  or  years,  and  who  shows  no  sign  of  organic  dis- 
ease of  the  urogenital  or  nervous  system,  as  a  sign  of  that  general  neurosis, 
hysteria.  In  children  hysteria  usually  occurs  in  a  monosymptomatic  form. 
The  children  who  suffer  from  enuresis  at  some  period  usually  come  of  a 
neuropathic  family,  and  later  show  some  other  symptoms  of  hysteria. 

Functional  Causes:  Adenoids. — It  is  not  infrequent  to  find  that  ob- 
structions of  the  nose  and  in  the  nasopharyngeal  spaces  can  cause  enuresis. 
One  of  the  most  frequent  causes  met  with  is  adenoids.  It  is  a  safe  rule  to 
examine  the  pharyngeal  vault  when  enuresis  exists.  My  experience  has 
been  that  over  50  per  cent,  of  the  cases  of  enuresis  seen  in  my  clinic  have 
adenoid  vegetations. 

Tight  Prepuce. — If  other  irritations,  such  as  a  tight  prepuce,  exist, 
then  circumcision  must  be  insisted  upon.  If  irritation  exists  in  the  urine 
on  account  of  an  excess  of  lithates  or  phosphates,  then  internal  treatment 
must  be  directed  toward  relieving  this  condition.  (Eead  article  on  "Lith- 
semia.") 

Prognosis. — The  prognosis  of  this  condition  is  usually  good.  In  ob- 
stinate cases  it  may  be  valuable  to  insist  on  a  change  of  air ;  thus,  removing 
the  patient  from  the  city  to  the  country  or  to  the  seashore  is  of  value  in 
some  severe  cases. 

Treatment. — A  very  bland,  non-irritating  diet,  consisting  of  cereals 
and  milk,  will  be  indicated.  All  spices,  alcoholics,  coffee,  and  tea  must  be 
prohibited.  Do  not  permit  liquids  to  be  taken  before  retiring.  It  is  also 
important  to  have  the  bladder  emptied  immediately  before  retiring. 

Drug  Treatment. — One  of  the  best  drugs  is  strychnine  in  doses  of 
^/loo  grain,  three  times  a  day,  gradually  increased.  In  addition  thereto 
small  doses,  V^o  grain,  gradually  increased,  of  the  extract  of  belladonna. 
When  a  general  atony  exists,  then  nothing  will  be  better  than  iron  given  in 
the  form  of  elixir  of  quinine,  iron,  and  strychnine.  Massage  and  gentle 
friction  of  the  whole  body,  cold  sponging,  especially  of  the  spine,  are  valu- 
able adjuvants  to   the  treatment  of  this  condition.     A  cold   douche   di- 


^Berl.  klin.  Woch.,  vol.  xxxviii,  No.   31. 


390  DISEASES  OF   THE   KIDNEY  AND  BLADDER. 

rected  to  the  spine,  especially  to  the  lumbar  region,  will  be  found  of  great 
assistance. 

Fowler's  solution  and  iron  are  very  valuable  in  weak  children. 

For  incontinence  of  urine,  internally  may  be  given : — 

IJ  Ext.  rhus  aromaticse,  fl 10  minims 

Syrupi   aromatici    20  minims 

Aq.  destillatse   q.  s.  ad     1  drachm 

Sig.:    This  amount  to  be  given  three  times  a  day\ 

Or:— 

IJ  Liq.  atropinse  sulphatis    . .  .• 1%  drachms 

Liq.    strychninge   hydrochloratis    45   minims 

Syr.  aurant q.  s.  ad     1  ounce 

Sig.:  For  a  child  14  years  old,  5  drops  at  night;  increase  gradually.  Younger 
children  in  proportion. 

Tlie  Use  of  Electricity. — Faradic  electricity  applied  over  the  bladder, 
and  also  over  the  lumbar  region  of  the  spine  for  several  minutes  every  day, 
and  gradually  decreased  to  every  two  or  three  days,  is  of  value  in  some 
cases. 

According  to  Thiemich,  excellent  results  are  obtained  by  means  of  pain- 
ful faradization,  not  necessarily  of  the  sphincter  vesicae,  but  of  the  arms, 
back,  or  thighs.  Care  should  be  taken  to  prevent  the  impression  that  the 
treatment  is  a  punishment,  but  instead  it  should  be  explained  that  the 
measure  is  certain  of  success,  even  though  painful.  More  than  one  appli- 
cation is  rarely  required  if  care  and  tact  be  exercised.  As  in  all  forms  of 
hysteria,  isolation  and  removal  from  home  are  the  most  potent  of  all 
remedies. 

Mechanical  Treatment. — The  passage  of  cold  sounds  and  the  dilatation 
of  the  urethra  by  this  means  are  sometimes  very  effectual.  Elevating  the 
foot  of  the  bed  is  of  value  in  some  cases.  The  child  should  not  be  allowed  to 
sleep  on  its  back.  To  prevent  this  position  it  is  advisable  to  tie  a  towel 
around  the  child's  body  so  that  the  knot  is  in  the  center  of  the  back.  This 
will  awaken  the  child  if  it  turns  on  its  back  and  will  compel  it  to  sleep  on 
the  side. 


PART  VI. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CHAPTER  I. 

DISEASES  OF  THE  NOSE  AND  THROAT. 

Acute  Nasal  Catarrh  (Rhinitis;  Coryza). 

Infants  sneeze  normally  during  the  first  few  days  of  life,  the  me- 
chanical irritation  of  dust  in  the  air  being  the  cause  of  the  same.  The 
great  difference  between  the  intrauterine  temperature  and  the  temperature 
of  the  air  renders  the  new-bom  baby  sensitive  and  invites  respiratory 
catarrh. 

Etiolo^. — ^The  micrococcus  catarrhalis  is  usually  found  to  be  the 
cause  of  this  condition.  Weakened  and  delicate  infants  are  more  susceptible 
to  the  development  of  nasal  catarrh.  For  this  reason  iafants  with  hereditary 
disease,  such  as  syphilis,  have  constant  catarrh. 

The  handkerchief  containing  dried  secretions  laden  with  bacteria  fre- 
quently disseminates  this  disease.  Children  who  are  too  warmly  clad  and 
muffled  are  rendered  more  sensitive ;  they  are  susceptible  and  usually  suffer 
with  rhinitis.  Recurring  catarrh  usually  indicates  the  presence  of  adenoids. 
The  vault  of  the  pharynx  should  be  explored  with  the  finger  for  a  positive 
diagnosis.  *■ 

Diagnosis. — Acute  nasal  catarrh  must  not  be  confounded  with  syph- 
ilitic rhinitis.  The  history  should  be  carefully  noted.  Rhinitis  is  one  of 
the  earliest  symptoms  of  measles ;  hence  the  buccal  mucous  membrane  should 
always  be  examined  for  the  presence  of  an  enanthem. 

If  the  temperature  is  high — 102°  to  103°  P. — and  there  is  an  eruption, 
tlien  the  possibility  of  measles  should  not  be  overlooked.  In  all  cases  of 
measles  the  pharynx  and  tonsils  should  be  carefully  examined.  Diphtheria 
of  the  pharynx  frequently  has  an  acute  rhinitis  associated  with  it.  Per- 
tussis is  very  often  preceded  by  rhinitis.  Inflammation  of  the  lachrymal 
duct  is  at  times  associated,  causing  acute  con]uncti\dtis.  Sometimes  the 
inflammation  will  extend  through  the  Eustachian  tube  and  cause  otitis. 
In  older  children  deafness  is  frequently  caused  by  closure  of  the  Eu- 
stachian tubes. 

Treatment. — Hygienic  Treatment:  Put  the  child  to  bed  if  there  is 
fever,  but  if  the  temperature  is  normal  then  keep  the  child  indoors  in  a 

(391) 


392 


DISEASES  OF  THE  NOSE  AND  THROAT. 


room  with  a  temperature  of  70°  F.  The  body  should  be  warmly  clad  after 
having  been  given  a  good  tub  bath,  followed  by  friction  with  a  coarse 
Turkish  towel, 

Ehinitis  tablets,  containing  the  following  ingredients,  for  the  prophy- 
lactic and  general  treatment  of  catarrh  of  the  nose  and  throat,  have  been 
used  by  me : — ■ 

IJ  Soda  salicylate 1  grain 

Tinct.   aconite    1   minim 

Tinct.  belladonna    ^/m    minim 

The  above  quantity  is  for  one  tablet. 

One  tablet  can  be  given  with  vi'ater  every  three  or  four  hours  to  a  child  2 
years  old;  smaller  children  in  proportion. 


Fiff.    115. — Atomizer. 


Medicinal  Treatment. — The  gastro-intestinal  tract  requires  cleansing. 
A  drachm  of  castor-oil  at  the  commencement  of  treatment  is  beneficial. 
The  best  drugs  are  quinine  and  bfelladonna  given  internally.  The  quinine 
chocolates,  1  grain  of  quinine,  can  be  given  to  a  child  1  year  old;  to  an 
infant  six  months  old  one-half  the  dose.  Fluid  extract  of  belladonna,  ^/^g 
to  %  minim,  three  times  a  day.  Salol  tablets,  containing  1  grain  of  salol, 
can  be  given  with  benefit  every  three  or  four  hours. 

Local  Treatment. — A  solution  of  adrenalin  chloride,  1  to  10,000,  may 
be  used  to  cleanse  the  nostrils  in  very  5^oung  infants.  In  older  children  a 
solution  of  1  to  4000  may  be  used  for  the  same  purpose. 

The  discharge  can  also  be  removed  by  irrigating  with  a  1  per  cent, 
boracic  acid  or  borax  solution  or  a  1  per  cent,  table  salt  solution,  contain- 
ing some  glycerine,  with  an  atomizer  (see  Fig.  115)  or  with  Lefferts's  poste- 
rior and  anterior  nasal  syringe,  followed  by  an  alboline  spray.  The  fol- 
lowing prescription  is  useful  for  the  nasal  toilet: — 

IJ  Table   salt    1  drachm 

Borax    1  drachm 

Water    8   ounces 


ACUTE  NASAL  CATARRH.  393 

Aspirin  or  novaspirin  in  1-  to  3-  grain  doses  every  three  hours,  depend- 
ing on  the  age  of  the  child,  is  indicated.  Locally,  the  inunction  of  the 
following  ointment  in  the  nostrils  will  lessen  the  thickened  nasal  secretion. 

R  Pulv.  camphor    5  grains 

Pulv.    acid   boric    10  grains 

Menthol    1  grain 

Vaseline    1  ounce 

Other  valuable  preparations  for  cleansing  the  naso-pharyngeal  spaces 
are  Dobell's  solution,  borolyptol,  and  glycothymoline. 

Dobell's  Solution. 

I^  Sodium    biborate     1    drachm 

Sodium  bicarb 1   drachm 

Glyc.  of  carb.  acid    2  drachms 

Water  to  make   %  pint 


Fig.    116. — Leflferts's  Posterior  and  Anterior  Nasal   Syringe. 

Borolyptol  contains  5  per  cent,  acetoboroglyceride ;  0.2  per  cent,  for- 
maldehyde, in  combination  with  the  active  antiseptic  constituents  of  pinus 
pumilio,  eucalyptus,  myrrh,  storax,  and  benzoin. 

This  is  a  very  bland,  mildly  astringent  solution  adapted  for  the  naso- 
pharynx. I  frequently  use  this  solution  as  a  menstruum  for  carbolic  acid 
or  bichloride.  All  solutions  used  in  the  nose  should  be  non-irritant ;  hence 
caustics  should  be  avoided. 

Setter's   Solution. 

IJ   Sod.  bicarb 1  ounce 

Sod.  biborate   1  ounce 

Sod.  benzoat    20  grains 

Sol.  salicylate    20  grains 

Eucalyptol    10  grains 

Thymol    10  grains 

Menthol     5  grains 

Oil  of  gaultheria    6  drops 

Glycerine    8^/4  ounces 

Alcohol    2  ounces 

Water    16  ounces 

Tablets  sold  in  shops  under  the  name  of  Seller's  tablets  can  be  dis- 
solved in  4  ounces  of  water.  They  are  of  the  same  strength  as  the  solution 
here  mentioned. 


594 


DISEASES  OF  THE  NOSE  AND  THROAT. 


Cocaine  and  eucaine,  which  are  so  valuable  in  adults,  should  not  be 
used  in  children.  My  preference  is  for  novocain.  In  older  children  the 
inhalation  of  equal  parts  of  tincture  of  iodine  and  aqua  ammonia  every 
half -hour  will  frequently  abort  the  disease. 

Dietetic  Treatment. — The  nursing  infant  should  be  fed  at  regular 
intervals.  If  bottle-fed  the  same  regularity  should  be  observed.  No  stimu- 
lants should  be  given.  It  is  unwise  to  give  codliver-oil  or  other  restoratives 
when  radical  treatment  is  called  for. 

Naso-phaeynge^l  Cataerh  Fkequently  Associated  with 
GrASTRic  Catarrh. 

The  association  of  naso-pharyngeal  catarrh  with  catarrh  of  the  stomach 
may  at  first  seem  .peculiar.     When,  however,  the  anatomical  relationship 


Fig.    117. — Lenox   Nasal   Douche. 


Fig.    118. — Graduated  Douche  Suit- 
able for  Older  Children. 


of  the  mucous  membrane  of  the  naso-pharynx  with  the  oesophagus  and 
stomach  are  considered,  an  extension  of  the  disease  can  easily  be  understood. 
There  are  certain  points  which  have  a  decided  bearing  on  the  etiology  of 
gastric  catarrh  when  caused  by  naso-pharyngeal  disease.     Such  are: — 

1.  The  fact  that  children  rarely,  infants  never,  expectorate.  When 
they  have  post-nasal  catarrh  and  there  is  an  irritation  from  mucous  or  muco- 
purulent secretion  infants  invariably  swallow  the  same.  It  is  for  this 
reason  that  the  old-fashioned  dose  of  ipecac  or  castor-oil  was  given,  not  to 
relieve  the  cough  nor  to  hasten  the  expectoration,  but  rather  to  cleanse  the 
stomach  from  non-expectorated  secretion. 

2.  Loss  of  Appetite. — The  loss  of  appetite,  usually  associated  with  se- 
vere naso-pharyngeal  catarrh  in  which  the  stomach  has  been  normal  up  to 
the  beginning  of  the  attack,  is  usually  due  to  the  swallowing  of  large  quan- 
tities of  this  infectious  secretion. 


INFLUENZA.  395 

The  benefit  derived  from  curing  a  cold  witli  a  dose  of  castor-oil  simply 
means  removing  some  of  the  swallowed  muco-purulent  secretion  from  the 
stomach  which  should  have  been  expectorated. 

When  catarrhal  disease  affecting  the  naso-pharyngcal  space  is  muco- 
purulent and  contiiiues  for  a  long  time  in  very  young  infants,  we  can  easily 
see  why  the  loss  of  appetite  may  be  the  means  of  causing  deficient  nutri- 
tion. Such  cases  may  end  fatally.  The  importance  of  attending  to  diseases 
in  the  naso-pharynx  can  be  seen  when  it  is  considered  that  diphtheria  can 
spread  from  the  pharynx  to  the  oesophagus,  and  also  to  the  stomach. 

While  it  is  true  that  diphtheritic  gastritis  is  reported  very  rarely,  it  is 
well  to  bear  such  cases  in  mind,  for  they  show  the  great  danger  to  the 
stomach  from  an  infectious  catarrh  located  at  the  food  entrance.  There 
is  usually  a  deficiency  of  hydrochloric  acid  secretion  in  all  severe  catarrhal 
diseases.  This  is  most  apparent  in  those  febrile  conditions  which  accom- 
pany diphtheria.  It  is  for  this  reason  that  it  is  not  very  difficult  for 
the  stomach  to  be  -the  seat  of  an  infection  if  diphtheritic  membrane  is 
swallowed. 

It  is  of  the  greatest  importance  to  have  every  child's  throat  in  a  nor- 
mal condition.  Adenoid  vegetations  and  diseased  tonsils  favor  the  devel- 
opment of  malignant  disease.  The  vast  majority  of  patients  who  are 
infected  with  diphtheria  owe  this  infection  to  the  diseased  state  of  their 
throat,  which  favors  the  development  of  pathogenic  bacteria.  This  can 
as  easily  be  verified  in  children  as  in  adults.  It  is  rare  to  find  a  case  of  diph- 
theria in  which  a  previous  normal  throat  existed.  Hence  it  would  seem 
plausible  to  eradicate  all  trifling  as  well  as  serious  nose  and  throat  disease, 
and  aim  to  secure  a  healthy  state  if  ive  are  to  ward  off  infections. 

Influenza  (La  Grippe). 

Commonly  known  as  "grip"  or  "epidemic  catarrhal  fever.". 

This  is  an  acute  infectious  disease  with  which  catarrhal  disturbances  of 
the  respiratory  or  gastro-intestinal  organs  are  usually  associated.  There 
is  also  a  profound  nervous  disturbance  with  marked  perspiration  and  very 
high  fever. 

The  disease  occurs  epidemically,  spreading  from  case  to  case  with 
great  rapidity,  so  that  it  was  formerly  attributed  to  meteorologic  condi- 
tions. It  is  for  this  reason  known  and  described  by  the  Germans  as  a 
•'Blitzkatarrh."  The  disease  occurs  most  frequently  in  cold  and  damp 
weather,  and  frequently  attacks  the  same  person  several  times. 

Bacteriology. — -The  disease  is  caused  by  a  very  small  bacillus,  about 
0.8  micro-millimeter  long  and  0.4  micro-millimeter  broad. 

This  bacillus  was  first  discovered  by  Pfeiffer,  in  1892.  It  stains  very 
intensely  at  the  ends  and  resembles  a  diplococcus. 


396 


DISEASES  OF  THE  NOSE  AND  THROAT. 


In  the  mucous  membrane  of  the  nose,  throat,  and  lungs  we  find  the 
greatest  number  of  bacilli;  thus,  it  is  reasonable  to  suppose  that  the  in- 
fection takes  place  through  the  respiratory  tract,  and  in  this  manner  the 
germs  gain  an  entrance  into  the  body. 

The  bacillus  of  PfeifEer  only  is  present  in  influenza.  The  poison  gen- 
erated by  this  germ  resembles  a  group  of  bacterial  proteins,  described  by 
Buchner.  Such  poisons  occur  within  germs  and  are  excreted,  but  only 
to  a  limited  extent,  in  the  media  in  which  they  groAv.  Examples  of  these 
germs  are  the  diphtheria  and  tetanus  bacilli.  Such  toxins  affect  the  cen- 
tral nervous  system  very  powerfully.  Thus  we  find  severe  nervous  depres- 
sion in  the  course  of  an  attack  of  influenza,  just  as  we  do  in  the  course 


Fig.  119. — Influenza  Bacilli.  Sputum  smear,  stained  with  dilute 
ZieM's  solution.  Bacilli  chiefly  intracellular;  most  of  them  show  thickened 
ends.     X800.      (Lenhartz-Brool<;s.) 


of  a  severe  case  of  diphtheria.  The  influenza  bacillus  is  frequently  asso- 
ciated with  other  pyogenic  bacteria.  The  tendency  of  mixed  infection  in 
the  course  of  influenza  is  to  generate  pus.  It  is  therefore  a  wise  plan  to 
examine  the  middle  ear  for  possible  suppurative  conditions. 

Not  infrequently  tuberculosis  is  associated  with  or  follows  a  severe 
attack  of  influenza. 

Symptoms. — When  children  are  old  enough  to  complain,  then  one  of 
the  most  frequent  subjective  symptoms  will  be  either  a  violent  headache 
or  pains  in  the  muscles  of  the  body.  In  young  children  and  nurslings 
violent  vomiting,  associated  with  diarrhoea,  may  be  the  initial  symptoms  of 
the  disease.  While  fever  usually  accompanies  an  attack  of  influenza,  there 
are  many  cases  in  which  a  subnormal  temperature  is  present.  As  has  been 
previously  stated,  chills  or  rigors  are  seldom  or  never  present. 

Convulsions  in  young  children  are  frequently  a  forerunner  of  an  attack 


INFLUENZA. 


397 


of  influenza.  The  differential  diag- 
nosis between  an  attack  of  measles 
and  influenza  is  sometimes  quite 
difficult.  Both  commence  with 
sneezing,  coughing,  and  catarrhal 
symptoms,  with  suffused  eyes,  and 
an  eruption  resembling  measles  may 
frequently  be  found  in  influenza. 

Diagnosis. — The  diagnosis  of 
this  disease  is  sometimes  very  diffi- 
cult. If  an  epidemic  exists,  or  if 
several  members  in  a  family  are  at- 
tacked with  grip  and  the  children 
suddenly  exhibit  symptoms  of  ma- 
laise or  have  a  disordered  stomach, 
and  show  high  fever  without  any 
apparent  reason,  then  influenza 
should  be  suspected.  If  catarrhal 
symptoms  associated  with  influenza 
present  themselves,  then  such  symp- 
toms are  of  a  more  severe  type  than 
those  usually  seen  in  simple  coryza. 

An  eruption  resembling  scarlet 
fever,  complicated  by  tonsillitis  or 
pharyngeal  symptoms,  will  baffle  the 
diagnostic  ability  of  the  physician, 
but  the  presence  of  influenza  in  a 
house  will  aid  in  eliminating  other 
diseases  and  assist  in  establishing 
the  true  diagnosis.  Not  infrequently 
a  child  will  suddenly  show  high  fever 
and  diarrhoea,  with  severe  nervous 
depression,  intense  thirst,  and  ty- 
phoid tongue,  with  hei'e  and  there 
small  lenticular  spots  which  may  so 
resemble  typhoid  fever  that  only  the 
course  of  the  disease  and  constant 
watching  will  aid  in  making  a  cor- 
rect diagnosis.  Where  such  sj^mp- 
toms  exist  we  must  resort  to  an 
examination  of  the  urine,  and  it  is 
here  that  the  diazo  reaction  will 
render  material  assistance.     In  ad- 


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Fig.  120. — Case  of  Influenza  Pneu- 
monia. Child  about  eight  months  old. 
Suffered  severe  prostration  from  the 
toxoomia.  Note  the  very  high  pulse-rate. 
Treatment  consisted  in  using  steam  im- 
pregnated with  beeehwood  creosote,  mild 
laxative  and  careful  diet.  Case  recov- 
ered.     (Original.) 


398  DISEASES  OF  THE  NOSE  AND  THROAT. 

dition  to  the  examination  of  the  urine,  the  Widal  reaction  should  be 
resorted  to.  If  both  the  Widal  and  the  diazo  reaction  are  absent,  and  if 
the  depression  and  the  catarrhal  symptoms  resembling  influenza  continue, 
then,  and  then  only,  should  the  diagnosis  of  influenza  be  made.  The  fever 
is  more  irregular  in  the  course  of  influenza  than  it  is  in  typhoid,  and  usually 
shows  an  evening  fall  and  a  morning  rise,  which  is  the  reverse  of  typhoid. 
The  skin  is  usually  very  pale  in  typhoid  and  flushed  in  influenza.  There 
are  three  definite  types  of  influenza  most  usually  met  with  in  children  :— 

1.  That  affecting  the  respiratory  tract. 

2.  That  affecting  the  gastroenteric  tract. 

3.  That  in  which  the  brain  and  nervous  system  are  largely  affected. 
Respiratory  Type. — When  the  respiratory  tract  is  involved  we  usually 

have  either  a  pharyngitis,  tonsillitis,  pneumonia,  or  a  broncho-pneumonia. 
When  a  very  young  child  shows  severe  broncho-pneumonia  and  there  is  a 
general  toxemia  associated  with  it,  then  the  prognosis  is  usually  very  bad. 
A  very  frequent  complication  in  this  condition  is  tuberculosis;  thus,  if 
tuberculosis  follows  a  severe  attack  of  influenza  in  a  young  child  whose 
-system  is  undermined  from  a  long  and  tedious  disease,  then  grave  results 
may  follow. 

Gastro-enteric  Type. — In  very  young  children  this  is  the  most  frequent 
form  of  influenza.  Vomiting  and  diarrhoea,  usually  accompanied  by  fever, 
will  be  found.  The  child  will  suddenly  refuse  to  take  the  breast,  if  it  is  a 
nursling,  or  refuse  to  take  bottle  if  it  is  hand-fed.  It  will  also  show  great 
restlessness  and  seem  dissatisfied  and  peevish.  The  sleep  will  be  disturbed, 
so  that  insomnia  is  a  very  frequent  symptom.  In  spite  of  careful  dietetic 
treatment  and  a  thorough  cleansing  of  the  gastro-intestinal  tract,  the  child 
will  show  the  same  clinical  picture  in  mid-winter  as  we  are  familiar  with  in 
the  course  of  a  severe  type  of  summer  complaint  in  mid-summer.  Convul- 
sions are  frequent,  though  not  always  present.  Such  children  suffer 
severely,  owing  to  tlie  malnutrition  and  owing  to  the  extreme  exhaustion 
following  a  continued  vomiting  or  diarrhoea.  They  lose  flesh  and  resemble 
the  atrophied  condition  following  an  acute  summer  complaint. 

Nervous  Type. — This  is  usually  the  most  serious  form  of  the  disease, 
involving,  as  it  does,  the  brain  and  the  nervous  system.  In  this  type  we 
meet  with  extreme  irritability,  and  if  the  child  is  old  enough  to  complain 
then  headache  forms  a  prominent  symptom,  so  also  will  pains  in  the  limbs 
and  in  all  the  muscles  of  the  body  be  complained  of.  Twitching  is  some- 
times a  marked  symptom;  convulsions  are  very  frequent. 

If  the  case  of  influenza  is  the  only  one  in  the  family  the  physician  may 
believe  that  he  is  dealing  with  a  meningitis.  Such  symptoms  as  photo- 
phobia, stupor,  coma,  retraction  of  the  head,  are  frequently  present; 
the  pulse  is  rapid,  tlie  temperature  is  frequently  very  high,  although  the 


INFLUENZA. 


399 


usual  tempei-aturc  ranges  ])etween  101°  and  103°  F.    When  severe  toxaemia 
exists  it  is  not  infrequent  to  find  a  subnormal  temperature. 

Complications. — The  influenza  bacillus  lias  a  tendency  to  develop  pus; 
hence,  a  nasopharyngeal  catarrh  may  extend  through  the  Eustachian  tube 
and  develop  mastoid.    If  influenza  attacks  the  lung  and  fever  persists,  look 


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Fig.  121. — Case  of  Influenza  Pneumonia  in  a  Child  Two  Years  Old. 
Note  the  irregular  type  of  fever  and  compare  the  steady  heart's  action  as 
indicated  by  the  pulse.     Child  recovered.     (Original.) 

for  empyema.  Be  sure  to  examine  the  urine,  as  influenza  may  cause  pyelitis, 
especially  if  the  fever  is  of  an  intermittent  character.  The  influenza 
bacillus  may  enter  the  frontal  sinus  through  the  nose  and  set  up  a  menin- 
gitis, which  may  be  of  a  suppurative  character, 

J,  Madison  Taylor  contends  that  neuritis  rarely  follows  influenza  in 
children,  whereas  it  is  a  common  sequela  in  adults. 

Nephritis  occasionally  complicates  influenza. 


400  DISEASES  OF  THE  NOSE  AND  THROAT. 

Milton  Miller^  reports  40  cases  of  influenzal  nephritis  taken  from 
literature.  He  reports  a  very  interesting  case  of  a  child  that  had  persistent 
vomiting  and  slight  diarrhoea;  later  on  oedema  of  the  limbs  and  suppres- 
sion of  urine. 

The  course  of  influenza  in  children  is  hard  to  define.  Some  children 
will  be  ill  a  week  or  ten  days;  others  will  show  the  evidence  of  systemic 
infection  months  after  an  attack  commenced.  For  this  reason  every  case 
of  influenza  should  be  carefully  supervised  during  the  convalescence. 

Prognosis. — ^This  depends  on  the  condition  of  the  child  prior  to  an 
attack.  If,  for  example,  an  infant  nursing  at  the  breast  is  attacked  with 
a  severe  form  of  influenza,  then  the  prognosis  may  be  reasonably  good.  If, 
however,  the  'Isottle  baby,"  with  an  existing  rickets,  is  attacked  in  a  similar 
manner,  then  the  prognosis  is  certainly  much  worse  than  it  would  be  other- 
wise; thus  the  general  systemic  condition  prior  to  the  infection  of  the  grip 
will  usually  suggest  the  probable  outcome  of  the  disease.  On  the  other  hand 
a  strong,  robust  child,  having  a  severe  form  of  influenza,  complicated  by 
middle-ear  disease,  with  mastoid  or  cerebral  complications,  necessarily  means 
a  bad  prognosis.  The  same  rule  would  apply  to  all  complications  following 
influenza,  in  which  exhaustion  from  a  lengthy  attack,  besides  the  difficulty 
of  properly  feeding  and  sustaining  life,  would  invite  a  fatal  termination. 

The  sheet  anchor  of  success  would  be  the  good  condition  of  the  heart, 
the  exclusion  of  kidney  complication,  and  also  the  fact  that  the  infant 
takes  a  reasonable  quantity  of  food.  A  progressive  weakness  of  the  heart 
or  the  devitalized  state  of  the  blood  from  prolonged  pneumonia  would  mean 
a  grave  prognosis;  thus  all  would  depend  on  limiting  the  extent  of  the 
disease  and  the  avoidance  of  complications. 

Treatment. — In  a  case  of  grip  it  is  advisable  to  isolate  the  child  affected 
from  the  other  children  in  the  family,  Next  to  isolation  the  child  must  be 
put  to  bed  and  kept  warm.  It  is  advisable  to  give  a  mustard  foot-bath  to 
stimulate  the  circulation,  and  follow  this  up  by  keeping  either  a  hot-water 
bag  or  bottles  of  hot  water  to  the  feet.  If  the  head  is  very  hot  an  ice-bag 
or  cold,  applied  by  ice-cold  handkerchiefs  to  the  head  in  the  region  of 
the  fontanels,  would  be  indicated.  If  high  fever  exists  then  15  to  30  drops 
of  sweet  spirits  of  niter,  repeated  three  times  in  intervals  of  one  hour,  will 
not  only  aid  the  kidneys,  but  also  have  a  slight  diaphoretic  effect. 

A  favorite  formula  of  mine  is  tincture  aconite  rad.,  1  drop,  combined 
with  spiritus  min^dereri,  %  teaspoonful,  freshly  prepared,  and  kept  in  a 
cool  place.  The  above  to  be  given  every  hour  until  the  temperature  is 
reduced  or  until  perspiration  appears. 

The  stomach  and  bowels  require  very  careful  attention  in  the  gastric 
type   of   this   disease;   thus   a  good  plan   is  to   commence   by   giving   a 


^Archives  of  Pediatrics,  January,  1902. 


INFLUENZA.  401 

small  tablet,  containing  V^o  grain  of  calomel,  with  a  little  water,  every 
hour  for  six  doses,  or  until  the  effect  of  the  calomel  is  manifested  by  the 
greenish  stools. 

If  the  child  is  old  enough  then  small  pieces  of  cracked  ice  or  ice  cream 
may  be  given  for  several  hours.  If  vomiting  persists  after  the  ice  cream 
then  nothing  should  be  given  by  mouth  for  six  hours. 

During  such  time,  when  there  is  severe  irritability,  medication  may  be 
given,  either  in  the  form  of  rectal  suppositories,  or,  if  possible,  by  hypo- 
dermic means. 

An  ice-bag  applied  at  the  pit  of  the  stomach  will  frequently  arrest 
vomiting.  An  ether  spray  over  the  epigastrium  for  a  minute  will  some- 
times relieve  a  persistent  vomiting. 

Liquid  food  in  a  concentrated  form,  such  as  broths,  soups  and  cereals, 
steak  Juice,  raw  beef  juice,  white  of  egg  and  water,  or  the  yolk  of  an  egg 
added  to  concentrated  soup,  is  very  nourishing  if  the  stomach  can  retain 
the  same.  Calisaya  is  one  of  the  best  tonics.  If  the  stomach  is  not  irri- 
table nitroglycerine,  in  doses  of  V200  grain,  will  do  good. 

Strychnine,  persistently  given,  is  indicated  in  the  course  of  convales- 
cence just  as  it  is  indicated  in  diphtheria. 

Peptonized  foods,  chiefly  milk  and  peptonized  broth,  may  be  neces- 
sary if  we  are  dealing  with  a  prolonged  gastric  type  of  the  disease  with  sub- 
normal digestive  power.  When  convalescence  is  established  then  syrup  of 
hypophosphites,  or  phosphorus  combined  with  codliver-oil,  or  the  glycero- 
phosphate of  lime,  will  be  found  advantageous. 

ISTo  matter  how  slight  an  attack  of  influenza  has  been  encountered,  it  is 
well,  when  convalescence  is  permanently  established,  to  insist  on  a  change 
of  air  to  the  South,  if  in  winter,  to  such  places  as  Virginia  Bay,  Old  Point 
Comfort,  or  Florida,  or  to  Lakewood,  or,  better  still,  Atlantic  City.  If  we 
have  encountered  a  severe  form  of  this  disease  with  extreme  emaciation  and 
loss  of  tone,  then  a  radical  change  of  air  to  a  more  balmy  and  permanent 
climate,  such  as  is  found  in  southern  California  or  in  New  Mexico,  should 
be  recommended. 

If  bronchial  catarrh  persists  with  expectoration,  or  if  we  are  dealing 
with  an  incipient  form  of  tuberculosis,  following  this  attack  of  grip,  then 
a  change  of  air  to  Colorado,  and  out-door  life,  may  be  the  means  of  arrest- 
ing the  disease  and  effecting  a  cure. 

Alcoholic  stiihulation  must  depend  on  the  individual  case.  If  the 
infant  assimilates  piilk,  broth,  cereals,  and  the  pulse  is  good,  then  alcoholic 
stimulation  is  unnecessary.  If,  however,  the  pulse  is  weak  and  very  little 
or  no  food  is  taken,  then  it  may  be  necessary  to  give  whisky,  especially  so 
if  the  pulse  is  feeble  and  the  heart  shows  signs  of  weakness.  Champagne 
may  be  given  if  persistent  vomiting,  with  exhaustion  and  heart  strain,  mani- 
fests itself. 

26 


402  DISEASES  OF  THE  NOSE  AND  THROAT. 

The  value  of  coffee  freshly  made,  to  which  some  milk  is  added,  must 
not  be  forgotten.    Caffeine  may  be  substituted  if  coffee  is  not  at  hand. 

Carbonate  of  ammonia,  in  doses  of  1  grain  for  a  child  1  to  3  years 
old,  repeated  every  two  or  three  hours,  will  be  useful  as  a  stimulant  during 
the  course  of  extreme  exhaustion  following  the  respiratory  type  of  this 
disease. 

To  stimulate  the  circulation  if  extreme  cyanosis  or  cold  extremities 
persist,  nothing  will  equal  judicious  massage.  Cupping  or  other  forms  of 
depletion  should  not  be  practised  nnless  severe  meningeal  symptoms  or 
constant  convulsions  demand  the  same.  Dry  cupping  over  the  chest  will  be 
found  useful  to  relieve  the  shortness  of  breath  at  the  onset  of  pneumonia. 

In  cupping  it  is  advisable  to  use  two  cups  anteriorly  and  four  cups 
posteriorly  at  the  same  time.  The  pulse  should  be  watched,  and  if  any 
irregularity  presents  itself  then  cupping  should  be  immediately  discon- 
tinued. 

The  depressing  effects  of  the  coal-tar  products,  such  as  antipyrine  and 
phenacetine,  should  be  remembered.  If  such  drugs  are  used  they  must  be 
combined  with  camphor  or  musk  to  counteract  the  depressing  effect  on  the 
heart. 

The  fever  is  rarely  so  high  that  we  must  resort  to  antipyretic  drugs. 
I  have  seen  good  results  from  sponging  the  body  with  alcohol  and  water, 
or  with  acetic  ether,  repeated  every  hour  or  every  half -hour  if  necessary. 
If  the  temperature  persists  a  cool  pack  should  be  applied  to  the  upper 
half  of  the  body.  This  pack  should  consist  of  a  sheet  wrung  out  of  cool 
water.  The  temperature  of  the  cool  pack  is  80°  F.  These  packs  should 
be  repeated  every  fifteen  minutes  if  the  temperature  is  105°  F.  or  over, 
and  every  thirty  minutes  if  the  temperature  is  103°  or  104°  F.  The  same 
treatment  should  be  continued  until  the  temperature  falls  to  102°  F.  or 
lower. 

Iron  may  be  necessary  for  months  after  an  attack  of  influenza.  One- 
teaspoonful  of  Peptomangan  (Gude)  after  each  meal  is  indicated.  The 
more  simple  forms  of  iron,  such  as  neoferrum,  are  easily  assimilated  by  a 
child.  A  preparation  that  the  writer  uses  frequently  is  tinct.  ferri  acet. 
seth.,  in  doses  of  5  to  20  drops  diluted  with  water,  three  times  a  day.  This 
form  of  iron  is  easily  digested,  will  restore  tone  to  the  system,  and  increase 
the  red  blood-corpuscles  if  continued  for  some  time. 

Foreign  Bodies  in  the  Nose. 

Children  frequently  while  playing  with  beans,  beads,  shot,  etc.,  stick 
them  in  the  nose.  If  allowed  to  remain  they  frequently  become  encrusted 
with  carbonate  and  phosphate  of  lime.  Then  it  is  Iniown  as  a  rhinolith. 
An  angular  forceps  or  a  polypus  forceps  has  frequently  dislodged  these 


TONSILLITIS.  403 

forei^  bodies.     A  nasal  irrigation  into  tlie  unoljstructed  nostril  will  some- 
times assist  in  rc'niovin<(  the  foreign  body. 

Tonsillitis   (Ax<iiNA  Catarrhalis)  . 

This  is  an  acute  inflannnatory  lesion,  undoubtedly  due  to  the  infection 
of  the  structures  of  the  tonsil  by  micro-organisms  which  enter  the  lacunae 
or  lymph  channels. 

Bacteriology  and  Pathology. — The  tonsils^  are  lymphoid  structures 
closely  reseinl)ling  Peyer's  patches  of  the  small  intestine.  Various  species 
of  cocci  and  bacilli  are  to  he  found  within  the  lacunae,  within  the  closed 
follicles,  and  even  within  the  epithelial  cells  of  tonsils  removed  during  the 
acute  stage. 

•  ,,/^^         '^  Y^k^i 


Fig.    122. — Angina  Tonsillaris.    Methylene-blue  Staining.     Zeiss  Immersion  1-12, 
Ocular  4.      (After  Jager,  Klin.  Microscopy.) 

Leucocytes  in  large  numbers  are  found  associated  with  the  microbes. 

During  the  presence  of  inflammatory  conditions,  such  as  the  presence 
of  the  contagium  of  diphtheria,  desquamation  of  the  epithelial  covering 
takes  place.  This  proliferation  of  the  cells  seen  in  diphtheria  may  entirely 
denude  the  tonsils  of  its  epithelial  covering  in  places.  This  will  then  per- 
mit any  specific  virus  to  be  brought  into  contact  with  the  lymphatics  and 
then  l)e  carried  into  the  general  circulation.  We  see  an  acute  inflammation 
of  the  tonsils  in  scarlet  fever,  in  measles,  and  in  diphtheria.  It  may  also 
be  seen  in  other  infectious  diseases,  so  also  in  acute  inflammatory  mani- 
festations. 

Symptoms. — One  of  the  most  fre^pient  diseases  of  infancy  and  child- 
Iiood  is  tonsillitis.    "When  we  are  told  that  an  infant  has  had  a  sliirht  fever 


^Hodenpyl  in  the  American  Journal  of  Medical  Science,  ^farch  1,  1891. 


404  DISEASES  OF  THE   NOSE  AND  THROAT. 

that  passed  off  very  quickly  and  has  been  attributed  to  "teething,"  tonsil- 
litis among  other  diseases  should  be  suspected. 

The  onset  is  sudden.  Fever  is  high.  The  temperature  reaches  103° 
and  may  rise  to  105°  F.  Vomiting  frequently  occurs.  On  the  tonsils  we 
find  intense  redness,  and  the  lacunse  are  covered  with  whitish  or  yelloAvish- 
white  spots,  which  rarely  coalesce  but  appear  as  yellowish  dots. 

Treatment. — Immediate  relief  to  an  inflamed  tonsil  can  be  given  by  a 
spray  of  1  to  10,000  adrenalin  chloride.  Externally  a  hot  flaxseed  poultice, 
or  in  some  cases  with  fever  an  ice  collar,  will  render  good  service. 

Internally  1-drop  doses  of  tincture  of  aconite,  repeated  every  hour  for 
five  or  six  doses,  will  reduce  fever,  promote  diaphoresis,  and  frequently  abort 
the  condition.  A  dose  of  calomel,  %  grain,  repeated  every  two  or  three 
hours  until  liquid  stools  are  produced,  is  valuable.  A  steam  atomizer  con- 
taining a  sj)ray  of  beechwood  creosote  or  pine-needle  oil,  to  be  used  every 
two  or  three  hours,  loosens  viscid  secretions. 

Food. — As  there  usually  is  pain  on  swallowing  solid  food,  it  is  better 
to  give  small  quantities  of  liquid  food.  Ice-cold  chicken  or  calfsfoot  jelly, 
ice  cream,  raw  scraped  pulp  of  meat,  the  yolk  of  raw  eggs  well  beaten  with 
sugar,  buttermilk  or  zoolak,  is  nutritious  and  grateful  to  an  inflamed  throat. 

The  Significance  of  Tonsillitis  in  Children. 

A  diagnosis  of  tonsillitis  or  quinsy  is  usually  thought  to  imply  that  we 
are  dealing  with  a  benign,  easy-going  condition.  That  the  reverse  is  true 
is  very  apparent  when  a  critical  inquiry  will  follow  the  termination  of  each 
and  every  case.  In  a  series  of  12  cases  of  follicular  tonsillitis  taken  at 
random  as  I  saw  them,  the  bacteriological  diagnosis  in  7  of  these  cases  was 
diphtheria. 

The  frequency  with  which  endocarditis  and  nephritis  are  seen  implies 
that  there  may  have  been  some  antecedent  disease  from  which  pathogenic 
bacteria  caused  the  valvular  heart  lesion,  or  possibly  a  nephritis. 

Follicular  Tonsillitis,  or  Follicular  Catarrh. 

Follicular  catarrli  is  the  most  frequent  form  of  inflammation  of  the 
tonsils. 

Bacteriology. — The  examination  of  the  purulent  pings  of  follicular 
angina  reveals : — 

(a)  Staphylococcus. 

(Tj)  Streptococcus. 

(c)  Pneumococcus. 


L  LC'KHU-.MEMJiRANULS  TONSIIJ.ITIS.  495 

Staphylococcus  an<iina  is  a  relatively  hannle.ss  iiiflniniiiatr)ry  lesion 
passing  oil'  without  coui})licalions. 

'JMie  streptococcus  variety  is  a  severer  type  of  disease  associated  with 
fever  and  glandular  enlargement.  This  disease  is  associated  frequently  with 
a  general  toxaemia  and  may  l)e  followed  hy  nephritis  or  septicaemia.. 

The  pneumococcus  fomi  is  usually  ushered  in  with  a  chill  and  some- 
times runs  a  course  similar  to  that  of  pneumonia.  There  is  usually  a  red- 
ness and  swelling  of  the  tonsils,  lacunar  catarrh,  and  increased  secretion, 
which  agglutinates  and  shows  itself  at  the  follicular  openings  as  yellowish- 
white  spots. 

The  lymphatic  glands  at  the  angle  of  the  jaw  are  sometimes  enlarged 
and  tender  on  palpation. 

Croupous  Toxsillitis. 

This  is  a  severer  form  of  inflammation  than  the  one  above  described. 
It  involves  the  whole  structure  of  the  tonsil  and  most  especially  the  crypts. 
The  large  quantity  of  fibrin  which  is  poured  out  forms  a  distinct  pseudo- 
membrane.  It  is  very  difficult  to  differentiate  this  from  diphtheria.  A 
culture  should  be  taken  in  all  cases  (see  the  "Diagnosis  of  Diphtheria"). 

We  cannot  differentiate  this  disease  from  true  diphtheria  clinically 
except  by  resorting  to  bacteriological  cultures. 

Ulcero-membeaxous  Tonsillitis. 

This  disease  was  first  described  by  Vincent^-  who  maintained  that  it 
was  caused  by  a  fusiform  bacillus,  although  a  spirillum  was  found  asso- 
ciated with  it. 

Microscopically,  there  is  a  spindle-shaped,  bacillus  along  with  sjurilli. 
The  bacillus  does  not  stain  with  Gram.     A  clear  culture  is  hard  to  obtain. 

The  pseudo-membranes,  whitish  or  grayish  in  color,  are  easily  detach- 
able until  the  third  da,j,  when  the  ulcer  fojms.  This  ulcer  corresponds 
to  the  portion  of  the  tonsil  occupied  by  the  ^jseudo-membrane.  Around  its 
edges  the  mucous  membrane  is  reddened.  The  accompanying  symptoms  are 
difficulty  in  swallowing,  fever,  anorexia,  headache,  and  swelling  of  the 
submaxillary  glands.  The  pseudo-membrane  does  not  increase  when  this 
piece  of  membrane  is  detached.    The  ulcer  heals. 

It  resembles  croupous  tonsillitis  in  its  general  appearance.  It  is  often 
unilateral.  The  yellowish  exudation  seen  on  the  tonsil  greatly  resembles 
diphtheria.  It  is  a  superficial  necrosis,  and  when  this  tissue  is  wiped 
away  with  a  swab  bleeding  occurs. 

There  are  swollen  lymph  nodes  at  the  angle  of  the  jaw. 


'Arch.  International  de  Laniigologic,  1S9S,  Xo.  1. 


406  DISEASES   OF    THE    NOSE    AND    THROAT. 

This  disease  is  a  local  process  and  rarely  has  constitutioiial  symptoms 
accompanying  it. 

Prognosis. — The  prognosis  is  excellent. 

Treatment. — Gargle  with  bichloride,  1  to  3000,  or  with  a  weak  solution 
of  permanganate.  Locally,  iodine,  or  3  per  cent,  peroxide  of  hydrogen  or  10 
per  cent,  nitrate  of  silver  solution,  can  be  repeated  in  twelve  hours  if  no 
improvement  is  noted.  By  painting  the  ulceration  with  a  3  to  3  per  cent, 
solution  of  neosalvarsan  freshly  made  with  distilled  water,  pains  and  symp- 
toms quickly  disappear. 


Fig.  123. — -Vincent's  Bacillus  Found  in  Ulcerative  Angina.  A,  Fusi- 
form bacillus  having  a  thickened  center  and  tapering  toward  both  ends. 
Also  spindle-shaped  bacilli.    B,  Fusiform  bacillus  having  spores.     (Original.) 

Phlegmonous  Tonsillitis  (Quinsy:  Peiritonsillar  Abscess). 

This  form  of  angina  is  usually  caused  by  an  invasion  of  the  staphy- 
lococcus. When  the  cellular  tissue  surroundingi  the  tonsil  is  infected  the 
inflammation  may  terminate  in : — 

(a)  Eesolution. 

(h)  Abscess. 

It  is  one  of  the  rarer  forms  of  inflammatory  conditions  met  with  in 
children. 

Symptoms. — ^The  symptoms  are  similar  to  those  of  follicular  tonsillitis. 
The  temperature  rises  to  101°  and  103°  F.     Sometimes  as  high  as  105°  F. 

The  child,  if  old  enough,  will  complain  of  pain  on  swalloAving,  and 
at  times  it  may  be  impossible  to  open  the  mouth.  On  examining  the  throat 
the  inflammation  can  be  seen.  There  is  a  marked  congestion  and  oedema 
involving  the  tonsils,  fauces,  and  uvula. 

Holt  reports  a  case  of  torticollis  several  days  before  the  diagnosis:  of 
quinsy  was  established. 


ClIltdMC    llVJ'KiriI{(»l'I!K'   TONSTLLCrrS. 


407 


Treatment. — Aconite  in  l-drop  doses,  repeated  every  one  or  two  hours 
for  the  iirst  day,  will  frequently  abort  the  disease.  Guaiacol  carbonate  given 
in  1-  to  5-  grain  doses  every  three  or  four  hours,  lias  served  me  very  well  in 
some  instances. 

Local  Treatment. — Local  treatment  consists  in  spraying  the  throat 
with  a  1  to  2000  bichloride  of  mercury  solution  every  two  hours. 

An  ice-bag  over  the  neck  will  sometimes  relieve  inflammation.  The 
external  application  of  leeches  will  relieve  congestion.     When  fluctuation 


Fig.    124. — Throat  Spray. 

is  felt  the  pus  should  be  relieved  by  making  a  deep  incision  with  a  long, 
pointed  bistoury. 

Tlie  Danger  of  Hcemorrhage. — Laryngologists,  as  a  rule,  advise  great 
caution  in  operating  in  this  region  owing  to  the  large  number  of  blood- 
vessels located  there. 

After  the  incision  is  made  the  wound  should  be  enlarged  by  inserting 


Fisr.    125.— Throat  Ice-baj; 


a  polypus  forceps  or  an  artery  clamp  and  separating  the  blades.  By  this 
means  we  can  easily  evacuate  the  pus  and  do  not  run  the  risk  of  l)leeding. 
I  am  indebted  to  Dr.  George  F.  Shradv  for  this  valuable  surgical  hint. 


ClIROXIC    liYrERTROriTIC    TOXSTLLITIS. 

The  chronic  enlargement  of  the  tonsils  is  due  to  r.xmrring  inflauimatory 
attacks.  This  hypertrophy  comes  from  a  ]iroliferation  of  the  lymphoid 
tissue  and  an  increase  in  the  connective  tissue  stroma. 

Etiology. — It  is  usually  found  in  rachitic  and  subnormal  children. 
Bad  ventilation  and  improper  hygiene  are  among  the  prime  causes  of  this 


408  DISEASES  OF  THE  NOSE  AND   THROAT. 

diseass.  In  a  series  of  several  hundred  children  examined  by  me  in  one 
of  my  clinics  for  various  diseases,  90  joer  cent,  suffered  with  enlarged 
tonsils.  All  of  these  children  lived  in  tenement  houses,  and  we  must  asso- 
ciate the  crowded,  ill-ventilated  apartments  with  the  poisoned  air  inspired 
and  its  resulting  throat  disease. 

Predisposing  causes,  such  as  rheumatism  in  the  parents,  have  been 
given  by  some  authors  as  causative  factors. 

Symptoms. — When  we  are  told  that  an  infant  snores  and  breathes  with 
its  mouth  open,  then  enlarged  tonsils  may  be  suspected  as  the  cause.  On 
the  other  hand  an  inspection  of  the  post-nasal  spaces  should  also  be  made 
to  eliminate  the  presence  of  adenoids  as  the  probable  cause  of  the  difficult 
respiration. 

Deafness  can  rarely  be  attributed  to  enlarged  tonsils.  It  is  more  often 
caused  by  the  closure  of  the  Eustachian  tubes  due  to  adenoids.  The  nasal 
tone  of  voice  often  accompanies  enlarged  tonsils. 

Course. — Enlarged  tonsils  increase  during  childhood  and  remain  per- 
manently until  puberty  arrives,  when  they  usually  shrink  in  size  without 
treatment. 

The  indications  for  the  removal  of  chronic  enlarged  tonsils  are: — 

1.  Where  there  are  repeated  attacks  of  tonsillitis. 

2.  Where  there  is  inability  to  breathe  sufficiently  through  the  nose, 
with  snoring,  during  sleep. 

3.  Nasal  voice  and  deficient  articulation. 

4.  Deafness  and  attacks  of  earache. 

5.  Tendency  to  pigeon-breast. 

When  any  or  all  of  the  above  conditions  exist  then  a  guarded  opinion 
should  be  given  until  we  ascertain  whether  or  no  the  case  is  complicated  by 
adenoids. 

-  In  the  latter  cases  the  removal  of  the  tonsils  will  not  suffice  to  cure  the 
patient  until  the  rhino-^Dharynx  is  treated  for  the  removal  of  the  adenoids. 

There  are  few  conditions  met  with  in  children  which  are  more  satis- 
factory from  a  therapeutic  standpoint  than  the  operation  for  tonsils  and 
adenoids. 

Dangers. — Desire^  collected  20,000  tonsillotomies.  In  9  cases  bleeding 
took  place.  In  none  of  these  cases  was  it  fatal,  and  in  several  it  was  not 
serious. 

Lefterts^  lays  stress  on  the  ascending  pharyngeal  artery  as  being  one 
of  the  most,  if  not  the  most,  prolific  source  of  severe  bleeding  after  ton- 
sillotomy. It  is  important  to  inquire  if  children  suffer  with  hcemophilia 
(bleeders)  ;  in  such  cases  fatal  haemorrhage  will  frequently  occur.     I  have 


^  Sajous's  Annual,  1891    vols,  iv  and  v. 
-Archives  of  Laryngologj^,  vol.  iii,  p.  43. 


rni^oNic  ii\im:r'I"R()imii('  ionsili.itis. 


409 


also  met  willi  a  case  of  congenital  syphilis  in  which  a  serious  haemorrhage 
followed  a  tonsiUotonn-.  This  was  evidently  due  to  a  syphilitic  degeneration 
of  the  Idood-vessels. 

The  Operation. — Tlie  l)istoury  is  rarel}^  or  never  used  for  this  opera- 
tion. Some  operators  use  a  wire  snare.  In  my  experience  the  adjustment 
of  a  snare  in  an  unruly  child  is  so  difficult  and  so  much  time  is  lost,  that 


Fig.    126. — The  Baginsky  Tonsillotome. 

it  is  not  practical.  ]\Iy  preference  has  been  for  some  form  of  tonsillotome. 
The  3Iackenzie  type  is  a  very  good  one.  The  Baginsky  tonsillotome  is  one 
of  the  best.  (See  illustration  Fig.  126.)  It  is  simply  a  sharp-bladed  guil- 
lotine and  can  be  very  easily  adjusted. 


Fig.    127. — The  Mackenzie  Tonsillotome. 


Haemorrhage  following  the  operation  need  not  cause  anxiety.  When, 
however,  lia?morr]iage  follows,  then  adrenalin  chloride  solution  in  full 
strength  (Viooo)  ^liould  be  liberally  used.  It  may  be  applied  in  the  form 
of  a  spray  or  by  means  of  a  cotton  pledget  soaked  witli  the  solution.  The 
galvano-cautery  or  the  local  application  of  peroxide  of  hydrogen  is  fre- 
quently useful.  In  older  children  small  pieces  of  cracked  ice  or  ice  cream 
will  control  Ideeding. 

The  Use  of  an  Anaesthetic.^ — The  local  application  of  a  10  per  cent, 
cocaine  s^oliition  has  lieen  recommended  bv  a  great  many  authors.     I  have 


^  Read  chapter  on  "Anaesthesia  in  Children,"'  page  885. 


410  DISEASES  OF   THE   NOSE  AND  THROAT. 

used  cocaine  in  cliildren  and  have  seen  very  bad  constitutional  effects,  such 
as  severe  cardiac  depression,  nausea,  and  frequently  vomiting,  following  its 
use.    I  prefer  4  per  cent,  novocains  solution. 

Spraying  the  tonsils  with  ethyl  chloride  for  several  seconds  produces 
local  anesthesia.  It  is  very  valuable  with  sensitive  children.  In  some 
instances  a  few  whiffs  of  chloroform  are  necessary  to  have  the  child  com- 
pletely under  control. 

Chloroform  is  very  rapid,  but  it  must  be  cautiously  given. 

It  is  advisable  to  operate  before  feeding,  so  that  in  the  event  of  vom- 
iting food  should  not  be  expelled. 

It  is  advisable  to  thoroughly  swab  the  mouth,  pharynx,  and  tonsils 
with  an  antiseptic  solution  before  the  operation.     For  this  purpose  use: — 

Table    salt    1   drachm 

Sterile  water 5  ounces 

Or  Dobell's  solution. 

Apply  with  a  cotton  swab. 

Normally  pathogenic  bacteria  abound  in  the  mouth  and  post-nasal 
spaces.  After  a  tonsillotomy  a  white  croupous  deposit  resembling  diph- 
theria will  be  seen.  This  should  not  be  considered  a  diphtheritic  infection 
unless  the  Klebs-Loeffler  bacillus  can  be  demonstrated. 

Owing  to  the  raw  surfaces  following  a  tonsillotomy  the  greatest  care 
must  be  used  to  isolate  the  patient  from  infectious  diseases.  Scarlet  fever 
and  diphtheria  will  gain  access  much  easier  soon  after  this  operation  is 
performed. 

Tuberculosis  of  the  Tonsils. 

Schlesinger  states  (Forts,  der  Med.  Pediatrics)  that  "up  to  the  present 
time  the  parallelism  between  advanced  tuberculosis  of  the  lungs  and  tuber- 
culosis of  the  tonsils,  as  also  that  between  mild  or  passed  tuberculous 
processes  of  the  lungs,  with  the  escape  of  the  tonsils,  has  only  been  demon- 
strated in  the  case  of  adults,  but  has  not  been  observed  in  children.  He  was 
able  to  confirm  this  parallelism  also  in  children,  having  found  13  cases  of 
tuberculosis  of  the  tonsils  in  13  of  florid  tuberculosis  of  the  lungs.  The 
diagnosis  of  tonsillar  tuberculosis  is  hardly  possible  microscopically,  for  the 
reason  that  tubercular  ulcerations  are  only  found  very  rarely  on  their 
surface;  neither  were  the  tonsils  hypertrophied  without  exception,  but 
were  found  pale  and  firm  in  nearly  two-thirds  of  the  cases.  In  9  cases 
examined  for  the  purpose,  the  tonsils  were  found  to  be  affected  bilaterally, 
although  not  with  equal  intensity.  As  to  the  relation  between  tuberculosis 
of  the  lymphatic  glands  of  the  neck  and  that. of  the  tonsils,  in  9  cases  the 
author  found  that  the  tonsils  were  healthy  in  2.  He  inclines,  therefore,  to 
the  view  that  a  primary  tonsillar  tuberculosis  is  not  to  be  taken  for  granted 
in  all  cases ;  but  we  must  take  into  account  the  possibility  of  their  infection 


ADENOID  VEGETATIONS.  411 

by  cheesy  cervical  glands,  by  means  of  the  return  flow  of  lymph.  The 
author  finds  some  support  for  this  view  from  the  fact  that  in  these  cases 
the  recent  tubercles  are  situated  at  the  base  of  the  tonsils  away  from  the 
crypts.^' 

L,  Kingsford^  examined  the  tonsils  removed  post-mortem  from  17 
children,  varying  in  age  from  4  months  to  9  years.  All  showed  cervical 
glandular  enlargement,  and  in  11  it  was  obviously  tuberculous.  Of  the 
17,  tonsillar  deposits  were  found  in  7,  but  only  3  exhibited  any  naked-eye 
tuberculous  changes.  Of  these  3,  1  showed  ulceration,  a  second  scarring,  and 
a  third  a  sebaceous  focus.  Practically  all  the  17  were  cases  of  secondary 
infection  from  either  blood  or  sputum.  The  parts  of  the  tonsils  which 
were  the  seats  of  the  lesions  were  usually  the  lymphoid  follicles  not  far 
from  the  epithelial  surface,  but  it  is  not  possible  to  trace  bacilli  in  from 
the  crypts  or  surface  of  the  organs.  The  author  believes  i1i  possible  that 
infection  may  work  through  healthy  tonsils  to  the  cervical  glands,  the 
former  becoming  infected  at  a  later  period. 

Tuberculous  tonsillitis  is  a  very  rare  affection.  The  tonsils  are  rarely 
if  ever  the  site  of  primary  inoculation  in  pulmonary  tuberculosis. 

Adenoids,  Adenoid  Vegetations.- 

Adenoid  vegetations  consist  of  a  hypertrophy  of  the  adenoid  tissue 
which  exists  normally  in  the  naso-pharynx. 

Pathology. — In  a  less  severe  form  the  growth  may  be  confined  to  the 
roof  of  the  naso-pharyngeal  cavity.  In  severe  forms  the  vegetations  are 
very  numerous,  irregular  in  shape,  and  extend  from  the  roof  of  the  cavity 
to  the  lateral  walls.  They  grow  from  the  fossa  of  Eosenmiiller.  They 
frequently  cover  the  orifices  of  the  Eustachian  tubes.  They  are  frequently, 
according  to  Hall,  between  the  enlarged  pharyngeal  and  faucial  tonsils,  and 
sometimes  the  adenoid  tissue  at  the  base  of  the  tongue,  the  so-called  lingual 
tonsil. 

Age. — The  new-born  infant  as  well  as  the  premature  infant  frequently 
has  adenoids,  therefore  heredity  must  in  a  measure  play  an  important  part 
in  the  etiology  of  adenoids.  As  a  rule  children  reaching  the  fourth  or  fifth 
year  without  adenoids  developing,  rarely  acquire  them  later  in  life. 

Symptoms. — The  "adenoid  habitus,"  the  pinched  expression  of  the 
nose  and  the  long  dravm  face,  are  very  typical.  There  is  frequently  lateral 
narrowing  of  the  alveolar  arch  and  prominence  of  the  upper  incisor  teeth. 
Owing  to  the  interference  of  respiration  the  mouth  is  kept  open.  The  lips 
are  swollen  and  thick. 


^  The  Lancet,  January  9,  1904. 

-  For  "Congenital  Adenoids,"  see  clinical  history  on  page  59. 


412 


DISEASES   OF  THE   ?sOSE   AND  THROAT. 


Spicer  has  directed  attention^  to  tlie  distention  of  the  transverse  nasal 
veins  as  one  of  tlie  indications  of  tlie  presence  of  adenoids. 

Deafness. — Deafness  is  frequently  caused  b}^  the  presence  of  adenoids. 
The  amount  of  interference  caused  by  the  adenoids  will  depend  on  the 
relation  of  the  Eustachian  tube  orifice  to  the  vault  of  the  ^sharjarx.  If  the 
orifice  be  situated  high  up,  a  small  amount  of  growth  will  occlude  it  and 
cause  auditory  trouble.  When  the  orifice  is  situated  low  down  there  may 
be  extensive  vegetations  without  the  Eustachian  tube  being  implicated. - 
The  voice  has  a  muffled 
sound  with  a  nasal  twang. 
The  letters  m,  n,  and  ng 
cannot  be  pronounced. 
Stuttering  or  stammering 
can  frequently  be  cured  if 
vegetations  are  removed ; 
the  explanation  being  that 
the  g^jasmodic  actions  of  the 
muscles  of  the  throat  are 
due  to  reflex  irritation. 
Earache  frequently  accom- 
panies adenoids. 

Bed  wetting  is  iisually  as- 
sociated with  adenoids. 
Among  several  hundred 
children  examined  in  the 
children's  service  of  a  large 
dispensary,  it  was  rare  to 
find  a  case  of  enuresis  that 
Avas  not  associated  with 
adenoid  vegetation. 

Diagnosis. — The  mouth  breathing,  the  snoring  at  night,  the  adenoid 
face,  are  in  themselves  sufficient  to  establish  a  diagnosis,  l^o  examine  tlie 
rliino-pliarynx  for  the  presence  of  adenoids,  have  the  nurse  seated  with  the 
child  on  her  lap,  firmly  pinning  the  child's  feet  between  her  knees.  While 
the  right  hand  confines  the  child's  arms,  tbe  left  hand  is  used  to  support 
the  head.  The  pliysician  should  then  separate  the  jaws  with  the  aid  of  a 
mouth  gag  and  explore  the  post-nasal  space  with  his  index  finger.  In  tlie 
absence  of  a  gag  a  clean  cork  or  the  handle  of  a  spoon  ^orotected  by  gauze 
can  be  used  to  separate  the  jaM'S. 

If  tbe  child  is  very  unruly  it  is  wiser  to  pin  a  sheet  securely  across 
the  arms  and  examine  in  the  dorsal  position. 


Fig.    r28. — Typical  Adenoid  Face  in  a  Cretin. 
(Oi-iginal.) 


^British  Medical  Journal,   ]8S7,   p.   459. 
^  Sajous's  Annual,  1888,  vol.  iii,  p.  278. 


PLATE  XYT 


Chronic  Enlarged  Tonsils  and  Associated  Congested  Throat,  very  frequently 

seen.      (Original.) 


A  case  of  Granular   Pharyngitis.     Large   masses   could   be   palpated   in   the 
rhino-pharynx.     (Original.) 


ADENOID  VEGETATIONS. 


413 


The  pliysiciaii  can  best  make  the  examination  by  standing  directly 
behind  the  child. 

Differential  Diagnosis. — In  making  a  diagnosis  of  adenoids  in  infants 
we  must  depend  upon  the  inability  to  nnrse  properly  and  noisy  mouth 
bi-eathing.  However,  many  other  cases  of  noisy  mouth  breathing  sliould  be 
excluded.    These  briefly  mentioned  are: — 

1.  Congenital,  as : — 

Diminution  in  size  or  occlusion  of  one  or  both  nostrils. 
Highly  arched  palate  or  deformity  of  soft  palate. 
Distortion  of  cervical 

vertelirge. 
Atelectasis. 

2.  Constitutional,  as :  — 

Syphilis. 
Lymphatism. 
Tuberculosis. 
Lithgemia. 

3.  Other  conditions,  such  as : — 

Acute  rhinitis. 
Eectopharyngeal        ab- 
scess. 
Disturbances  of   diges- 
tion. 
Paralysis  of  soft  palate 

or  pharynx. 
Diphtheria,     especially 
nasal. 

These  have  to  be  carefully  considered.  These  conditions  may  exist 
■^rith  adenoids,  but  when  alone  may  cause  symptoms  similar  to  those  occa- 
sioned by  the  presence  of  the  hypertrophied  tissue,  so  an  operation  may 
not  result  in  the  promised  cure.  In  infants  the  examining  finger,  on 
account  of  its  size,  is  out  of  the  question,  and  the  rhinoscopic  mirror  cannot 
l)e  employed.  To  be  absolutely  certain  the  curette  must  establish  the  diag- 
nosis. 

Prognosis. — The  disorders  arising  from  the  presence  of  adenoids  are: 
Repeated  attacks  of  coryza.  chronic  rhinitis,  arrest  of  nasal  development, 
nasal  stenosis,  and  mouth  liroathing,  with  the  associated  mental  listlessness. 
There  is  a  tendency  to  bronchitis,  to  spasmodic  croup  and  asthma.  Children 
with   adenoids  usually  have  very  poor  ajipetites.     There  is  an   associated 


Fig.   129. — Digital  Method  of  Exploring 

the  Rhino-pharynx  for  Adenoids. 

(Original.) 


414  DISEASES  OF  THE  NOSE  AND  THROAT. 

gastric  catarrh.  Some  authors^  state  that  measles,  scarlet  fever,  and  ear 
troubles  are  more  frequently  found  in  children  where  adenoids  exist.  Their 
presence  is  therefore  a  menace  and  they  certainly  invite  infection. 

Treatment. — It  is  best  to  use  an  anodsilietic,  as  most  children  with 
adenoids  are  of  a  neurotic  temperament.  Be  sure  the  child  has  neither 
heart  nor  kidney  trouble  before  deciding  upon  an  anaesthetic.  If  either 
condition  exists,  operate  without  an  anaesthetic. 

A  rapid  anaesthetic  in  children  is  chloroform.  Some  authors  advise 
the  use  of  nitrous  oxide  followed  by  ether  as  the  best  means  of  producing 
anesthesia.  Deep  anaesthesia  is  uncalled  for,  as  in  that  condition  the  cough 
reflex  would  be  abolished.  It  is  better  to  do  the  operation  completely  rather 
than  put  a  child  to  the  pain  and  discomfort  of  repeated  sittings.  Two  or 
more  sittings  may  be  necessary  if  the  child  is  not  anaesthetized.  The  evening 
before  the  operation  a  1-grain  dose  of  calomel  or  a  wineglass  of  citrate  of 
magnesia  has  a  beneficial  effect  on  the  bowels.  The  position  of  the  child 
during  the  operation  is  of  great  importance.  Some  operators  prefer  the 
head  over  the  end  of  the  table.  Butlin^  says  the  patient  should  lie  on  the 
side  with  the  thighs  flexed,  the  head  a  little  forward  on  a  low  pillow. 

The  Operation. — The  Gottstein  curette  or  its  modification  is  best 
adapted  to  work  in  the  antero-posterior  diameter  of  the  naso-pharynx.  The 
Lowenberg  forceps  or  its  modification  is  used  to  grasp  the  mass  and  is 
preferred  by  many  operators. 

With  the  curette  the  portion  removed  is  apt  to  be  lost  and  might  even 
drop  into  the  larynx,  although  it  is  the  safest  instrument  to  use  with  very 
young  children.  The  best  type  of  forceps  is  the  Graedle  or  its  modification 
by  Concannon.  This  forceps  has  an  extensive  cutting  edge,  hence  tearing 
is  unnecessary. 

Operating  Without  an  Ancesthetic. — The  child  should  be  placed  in  an 
upright  position  and  held  by  an  assistant.  A  mouth  gag  is  used,  and  the 
closed  forceps  is  introduced.  The  forceps  is  then  opened  widely  and 
pressed  well  upward  and  behind.  The  mass  is  seized  and  the  forceps  with- 
drawn. The  finger  should  always  be  introduced  to  be  sure  of  the  location 
and  extent  of  any  remaining  masses.  The  latter  can  be  removed  with  the 
finger,  curette,  or  with  smaller  forceps. 

If  the  Gottstein  curette  is  used  it  should  be  carried  well  up  into  the 
vault,  carrying  the  soft  palate  forward;  then  it  should  be  brought  down 
with  a  bold  sweep,  to  the  vault  of  the  pharynx.  The  steel  nail  is  frequently 
advised  by  some  operators  as  a  means  of  removing  adenoids.  In  spite  of  the 
most  careful  treatment^  adenoids  will  frequently  recur. 


'  Centralblatt,  vol.  i,  p.  278. 

==  Lancet,  vol.  i,  189.3,  p.  363. 

«W.  K.  Simpson    February  13,  1902. 


PHARYNGITIS.  415 

Ilcemorrhages  After  Operation. — ^The  local  application  of  diluted 
peroxide  of  hydrogen,  or  Monsell's  solution  undiluted,  is  sufficient  to  control 
any  ordinary  haemorrhage.  If,  however,  it  is  a  case  of  haemophilia  or  pro- 
fuse bleeding,  then  the  subcutaneous  injection  of  30  cubic  centimeters 
sterile  horse  serum  into  the  thigh  or  abdomen  will  control  the  bleeding. 

Thromboplastine,  obtainable  at  the  Eesearch  Laboratory  of  the  New 
York  Board  of  Health,  has  recently  been  recommended  by  Hess.  It  is 
markedly  haemostatic  and  somewhat  antiseptic  in  action,  and  should  be  ap- 
plied locally  for  a  few  minutes  to  bleeding  surface  by  means  of  cotton  or 
gauze.  If  applications  do  not  stop  the  bleeding,  inject  some  of  the  clear 
solution  into  the  site  of  the  haemorrhage. 

For  gastric  or  intestinal. haemorrhage,  the  contents,  of  1  vial  (20  cubic 
centimeters)  should  be  diluted  with  8  ounces  of  water  and  taken  by  nlouth. 
This  may  be  given  several  times  in  the  course  of  the  day.  Plugging  the 
nostril  with  gauze  saturated  with  thromboplastine  is  very  efficacious  in 
haemorrhage  caused  by  exfoliation  of  diphtheritic  membrane.  This  has 
been  used  by  me  at  the  Willard  Parker  Hospital  with  excellent  result. 

Codliver-oil  and  malt  extract  are  among  the  restoratives  indicated  for 
the  after-treatment.  The  most  important  part  of  the  after-treatment  con- 
sists in  the  strict  application  of  hygienic  measures.  The  child  should  be 
placed  in  a  room  in  which  there  is  fresh  air,  windows  open  night  and  day. 
If  a  child  is  old  enough  we  should  teach  it  how  to  breathe.  Out-of-door 
exercise  should  be  insisted  upon.  Deep  inspiration  and  expiration,  and 
pulmonary  gymnastics  are  just  as  important  as  attention  to  the  food.  Milk, 
meat,  eggs,  cereals,  and  fruits  should  be  ordered,  depending  on  the  age  and 
requirements  of  the  case. 

Phaetn"gitis. 

The  proximity  of  the  pharynx  to  the  tonsils  renders  this  portion  of 
the  body  very  prone  to  harbor  pathogenic  bacteria.  Infections  therefore 
spread  from  the  tonsils  to  the  pharynx  or  from  the  uvula  to  the  pharynx. 
In  the  article  on  tonsillitis  I  refer  to  this  region  as  an  avenue  for  infection 
through  which  tubercle  bacilli  may  enter  the  lymph  channels  and  set  up  a 
posterior  basic  meningitis.  The  diplococcus  intracellularis  can  also  enter 
the  pharynx  and  by  this  channel  set  up  a  cerebrospinal  meningitis.  The 
pharynx  js  therefore  an  important  part  of  the  body  to  be  inspected  when 
obscure  febrile  conditions  exist. 

Treatment. — Local  applications  of  dilute  Lugol's  solution  applied  to 
the  retropharynx  once  only  by  means  of  a  cotton  swab,  and  a  spray  of 
DobelFs  solution  after  feedins^  and  at  nisrht  before  retirine-  is  a  <jood  means 
of  destroying  pathogenic  bacteria  in  influenza  or  in  catarrhal  infections. 
During  an  epidemic  it  is  good  to  employ  the.  Dobell  spray  as  a  prophj'lactic. 


416  DISEASES   OF   THE   NOSE  AND  THROAT. 

Eetropharyngeal  Abscess  (Eetropharyngeal  Lymph  Adenitis). 

This  condition  may  be  clue  to  meclianical  irritation  or  to  direct  infec- 
tion.   The  most  common  forms  met  with  in  children  are  evidently  due  to : — 

1.  Local  infection. 

2.  Abscess  caused  by  a  tubercular  infection  or  where  caries  of  the 
cervical  vertebrte  exists.  This  latter  condition  we  meet  in  older  children. 
It  is  usually  a  sequel  to  the  specific  infections^,  and  may  follow  scarlet  fever, 
measles,  or  diphtheria.  It  is  most  frequently  associated  with  influenza  and 
tuberculosis.  Eachitic  and  syphilitic  children  are  predisposed  to  this  dis- 
ease.    Catarrhal  affections  of  the  upper  air  passages  also  invite  this  disease. 

Pathology. — The  retropharyngeal  lymph  nodes  are  described  (Simon) 
as  forming  a  chain  on  each  side  of  the  median  line  betAveen  the  pharyngeal 
and  prevertebral  muscles;  these  undergo  atrophy  after  the  third  year. 
Sometimes  adenoids  will  cause  a  swelling  of  the  glands,  giving  rise  to  fever, 
but  they  will  not  suppurate.  At  other  times  the  swelling  of  the  retro- 
pharyngeal lymph  nodes  will'  Be  associated  with  external  cervical  adenitis. 
It  is  important  to  recognize  this  condition  owing  to  the  serious  nature  of 
the  disease. 

Symptoms. — This  affection  usually  develops  very  suddenly;  the  infant 
will  refuse  the  breast  or  have  trouble  in  swallowing.  The  food  is  most 
commonly  regurgitated  through  the  nose.  Such  infants  will  have  labored 
mouth  breathing.  The  head  is  thrown  back,  there  is  severe  dyspnoea,  occa- 
sionally asphyxia — laryngeal  stenosis  due  to  pressure  of  the  abscess  on  the 
larynx,  interfering  with  respiration.  There  is  a  peculiar  snoring  sound. 
With  the  index  finger  in  the  throat  the  soft  fluctuating  tumor  can  be  felt. 
On  examining  the  throat  with  a  good  light  the  bulging  of  the  phar3'ngeal 
wall  will  be  noticed. 

The  temperature  will  range  from  103°  to  103°  F.,  sometimes  higher. 

Diagnosis. — The  diagnosis  should  be  made  with  the  finger,  by  a  careful 
palpation  of  the  post-nasal  and  pharyngeal  spaces.  Mouth  breathing  due 
to  adenoids  will  not  cause  sudden  symptoms  of  suffocation.  The  sudden- 
ness of  interference  with  respiration  points  to  the  development  of  an  abscess. 
The  following  cases  will  illustrate  this  condition : — 

Case  I. — An  infant  about  fifteen  months  old  was  brought  to  my  office  by  Dr.  J. 
Martinson.  The  liistory  was  loss  of  appetite,  regurgitating  of  food  through  the  nos- 
trils, mouth  breathing,  and  bulging  of  the  pharyngeal  wall.  Temperature,  101°  F. 
Cervical  glands  enlarged.  The  diagnosis  of  retropharyngeal  abscess  was  made.  An 
incision  made  in  the  abscess  liberated  the  pus.  The  abscess  cavity  was  cleansed 
with  a  1  to  2000  bichloride  solution.     The  child  recovered. 

Case  II. — A  nursing  infant,  less  than  1  year  old,  seen  with  Dr.  J.  Brandeis,  suf- 
fered with  retropharyngeal  abscess.  The  treatment  consisted  in  hot  fomentations. 
When  fluctuation  was  detected,  an  incision  was  made  Avith  a  curved  bistoury;  the 
lower  half  of  the  blade  was  protected  with  cotton.     After  the  incision  the  wound 


Rl'AS.MODIC   L.\HVN(;rriS. 


417 


waa  enlarged  by   introducing  and  separating  the  bladfs  of  a   pDlypus   forceps.     The 
child  recovered. 

BEC.bz.     13  \A-         15  le  n  18  19 


Fig.    130. — Temperature    C'liart   from    a    Case   of    Retropharyngeal    Abscess. 

(Original.) 

Treatment. — Some  children  require  local  applications.  Antiphlogis- 
tine  is  a  convenient  local  application  until  suppuration  is  established.  Flax- 
seed poultices  are  sometimes  well  borne. 

No  time  should  be  lost  if  pus  is  present.  The  abscess  cavity  should 
be  opened  and  the  pus  liberated.  To  prevent  the  pus  flowing  into  the 
trachea,  it  is  best  to  keep  the  head  well  forward.  The  use  of  a  gag  is  not 
necessary  if  the  tongue  is  depressed  and  the  incision  made  with  a  small- 
bladed  knife  similar  to  a  tenotome.  After  the  pus  is  evacuated  tlie  parts, 
should  be  cleansed  with  a  1  per  cent,  carbolic  solution  oi)  a  1  to  2000 
bichloride  solution,  and  the  Avound  treated  on  general  aseptic  principles. 
Restorative  treatment  will  consist  in  giving  codliver-oil,  hypophosphites, 
and  last,  but  not  least,  food  and  fresh  air. 


Spasmodic  Laryngitis  (Catarrhal  'CROur:    Spasmodic  Croup). 

This  form  of  acute  catarrhal  spasm  was  first  described  by  Goodhart. 
The  disease  is  simply  an  acute  catarrhal  inflammation  associated  with  a 
severe  spasm  of  the  larynx.  Infants  under  six  months  of  age  are  rarely 
affected,  and  until  5  years  the  disease  is  most  common.  It  occurs  as  fre- 
quently in  well-nourished  as  in  frail  rachitic  children. 

Catarrhal  or  spasmodic  croup  is  frequently  the  result  of  hypersecretion 
in  the  naso-pharynx.  When  croup  appears  siiddevly  it,  shoidd  not  he  feared, 
especially  so  if  the  child  was  well  during  the  day.  It  simply  results  from 
post-nasal  secretions  accumulating  while  the  child  lies  on  its  back.     Such 


418 


DISEASES  OF  THE  NOSE  AND  THROAT. 


croupous  attacks  will  always  yield  to  a  good  emetic  dose  of  syrup  of  ipecac. 
Such  children  while  awake  suffer  from  the  irritation  of  the  secretion  and 
swallow  the  same  by  day.  A  point  to  remember  in  this  connection  is  that 
croup  which  is  fatal  or  serious  comes  on  very  slowly  and  cannot  be  per- 
manently benefited  by  giving  an  emetic. 

Symptoms. — The  symptoms  are  similar  to  those  of  laryngeal  diph- 
theria. It  is  at  times  very  difficult  to  differentiate  catarrhal  spasm  of  the 
larynx  from  diphtheritic  croup.  It  is  frequently  found  in  infants  with 
adenoid  vegetations  and  post-nasal  catarrh.  An  inflamed  uvula,  diseased 
tonsils,  and  pharyngeal  catarrh  are  among  the  contributing  factors.  The 
mucous  membrane  is  red  and  swollen.  At  first  it  is  dry,  but  afterward  it  is 
covered  with  a  watery  mucous  secretion.  The  catarrh  may  begin  in  the 
subglottic  portion  of  the  larynx  and  may  be  associated  with  cedema  of 


Fig.    131. — Oil  Atomizer. 


mucous  membrane.  It  usually  follows  catarrh  of  the  nose  and  pharynx,  or 
it  may  be  an  extension  of  the  disease  from  the  bronchi. 

Children  suffering  from  this  form  of  croup  will  usually  have  repeated 
attacks  of  the  same.  The  slightest  exposure  to  cold  and  irritation  by  dust 
are  among  the  exciting  causes. 

After  an  attack  of  rhinitis  lasting  one  or  more  days,  the  child  will 
suddenly  awaken  at  night  with  a  hoarse,  barking  cough  and  the  face  will 
be  extremely  congested.  The  attack  terminates  by  a  long,  noisy,  high- 
pitched  inspiration. 

On  inspiration  we  note  deep  recession  of  the  suprasternal  fossa,  the 
supraclavicular  spaces,  and  the  epigastrium.  There  is  also  depression  of 
the  intercostal  spaces  and  the  walls  of  the  chest.  The  pulse-rate  will  be 
greatly  accelerated.  The  temperature  rarely  rises  over  103°  F.,  although 
in  some  instances  it  may  reach  103°  F.  Owing  to  the  dyspnoea,  children 
will  usually  gasp  and  try  to  sit  up.     The  forehead  and  sometimes  the 


SPASMODIC  LARYNGITIS. 


419 


whole  body  will  be  covered  with  large  beads  of  perspiration  after  an  attack 
of  laryngeal  spasm. 

Prognosis. — ^This  is  invariably  good.  A  point  to  remember  is  that 
when  croup  appears  suddenly,  it  is  of  a  mild  type  resulting  from  catarrhal 
trouble.  The  dangerous  form  of  croup  comes  on  very  slowly,  and  in  this 
type  we  must  always  look  for  diphtheria  as  a  causative  factor. 

Treatment. — In  the  treatment  of  diseases  affecting  the  air  passages  we 
aim,  roughly  speaking,  at  two  things  :— 

First. — To  relieve  the  cough. 

Second. — To  cure  the  disease. 


Fig.    132. — steam  Atomizer. 


Directions  for  Using  a  Steam  Atomizer. — Put  the  liquid  to  be  atomized 
in  the  cup  D.  Fill  the  boiler  F  about  one-half  full  of  water.  Fill  the 
lamp  I  with  alcohol  (use  nothing  but  alcohol  in  the  lamp),  and  after 
lighting  it  place  it  under  the  boiler.  As  soon  as  the  water  boils  the  medi- 
cated steam  will  be  thrown  out  through  the  tube  E,  and  can  be  inhaled 
through  the  shield  A. 

Local  Treatjiext. 

Iji  Table  salt 1  drachm 

Warm  water    1  pint 

Or:  — 

IJ  Bicarb,   of   soda    1  drachm 

Warm  -water    1  pint 


420  DISEASES  OF  THE  NOSE  AND  THROAT. 

Or:— 

Ij^  Tr.   ferri   chloridi 1  drachm 

Glycerine    1  ounce 

Water   1  ounce 

Or:— 

ij  Menthol 5  parts 

Alboline   100  parts 

Or:— 

IJ  Menthol    5  parts 

Paroleine  100  parts 

Either  of  the  above  solutions  can  be  used  in  the  form  of  a  spray  every 
two  or  three  hours.  This  lubrication  soothes  the  mucous  membrane. 
Guaiacol,  2  per  cent,  solution,  dissolved  in  alboline,  can  also  be  used, 

IJ  Balsam  of  Peru   %  drachm 

Oil  of  eucalyptus    i^  drachm 

M.  Sig. :  Dissolve  in  2  drachms  of  alcohol.  A  teaspoonful  into  a  pint  of 
boiling  water,  to  be  used  in  the  form  of  a  spray,  by  means  of  a  steam  atomizer. 
(Fig.  133.) 

Local  applications  of  iodine  and  glycerine  are  frequently  valuable: — 

IJ   Iodine  3  grains 

Glycerine    1  ounce 

Kali   iodide    5  grains 

M.     Sig. :     Apply  with  a  cotton  swab,  on  larynx.     Once  daily. 

When  this  catarrh  persists,  a  single  application  of  the  following  will 
frequently  abort  an  acute  attack: — 

3  Argenti    nitrici    10  grains 

Aquae  destillatse  1  ounce 

M.     Sig.:     Apply  cautiously  over  the  larynx. 

Emetics. — The  most  rapid  method  of  relieving  catarrhal  accumula- 
tions is  in  giving  an  emetic.  The  choice  of  the  same  depends  on  indi- 
vidual experience.  A  safe  and  harmless  emetic,  quite  rapid  in  action,  is  a 
teaspoonful  of  syrup  of  ipecac.  The  same  dose  may  be  repeated  in  half  an 
hour  if  not  effectual.  Syr.  scillse  eomp.,  commonly  known  as  Oox^s  hive 
syrup,  in  teaspoonful  doses,  is  also  a  mild  drug,  producing  emesis.  Mustard 
water  and  sulphate  of  zinc  are  also  useful.  Tartar  emetic  in  ^/^Q-grain 
doses,  gradually  increased,  is  valuable.  My  favorite  emetic  is  sulphate  of 
copper,  1-grain  doses,  with  %  ounce  or  less  of  water.  This  usually  produces 
an  instantaneous  effect. 

When  children  are  obstinate  and  will  not  swallow,  a  VigQ-grain  or  V25- 
grain  tablet  of  apomorphia,  given  hypodermically,  may  be  repeated  in  ten 
or  fifteen  minutes  if  necessary.  This  is  a  convenient  and  rapid  means  of 
producing  emesis.  Emesis  should  not  be  repeated  oftener  than  once  in 
twenty-four  hours,  and  then  always  with  due  regard  to  the  condition  of  a 
child. 


NIGHT  cordir. 


421 


Inlialations  of  steam  impregnated  with  turpentine  or  pine-needle  oil 
have  swerved  me  ver}'  -well.     For  producing  this  steam  a  croup  kettle  or 

a  steam  atomizer  may  be  used. 

The  steam  loosens  the  viscid 
secretion  and  can  be  used  every  hour 
or  less  often,  depending  on  the 
iirgency  of  the  case. 

Foreign"  Bodies  ix  the  Laryxx. 

Foreign  bodies  such  as  fish- 
bones or  particles  of  food  are  occa- 
sionally aspirated  into  the  larynx, 
causing  coughing  and  irritation.  In 
some  cases  laryngeal  stenosis  and 
symptoms  of  asphyxia  result.  Xo 
time  should  be  lost  in  commencing 
treatment,  owing  to  the  danger  of 
suffocation. 

The  hypodermic  injection  of 
apomorphia  {^/^o  grain)  until  emesis 
is  produced,  or  syrup  of  ipecac, 
several  teaspoon  fuls  given  by  mouth, 
will  occasionally  dislodge  the  foreign 
"body.  If  this  is  not  successful  a  laryngologist  should  be  sent  for.  A 
physician  who  is  inexperienced  with  the  larynx  should  refrain  from  pro- 
longed attempts  to  dislodge  the  foreign  bod}^  as  in  most  cases  only  harm 
can  result  therefrom.  If  asphyxia  threatens,  tracheotomy  should  be  per- 
formed. Those  experienced  with  intubation  should  first  try  the  effects  of 
the  large  caliber  tube  known  as  the  foreign-body  tube  (see  chapter  on 
"Intubation"). 

Coughs  of  Eeflex  Origix. 
Night  Cough. 

A  very  troublesome  fomi  of  cough  is  frequently  heard  at  night.  The 
history  given  is  that  the  child  is  c|uite  well  during  the  day,  but  has  a  dis- 
tressing cough  at  night. 

The  position  of  the  child  on  its  back  permits  naso-pharyngeal  accu- 
mulations to  stagnate ;  hence,  this  cough  occurs  when  the  cliild  is  on  its 
back.  A^er}^  young  children  do  not  expectorate,  nor  can  they  clean  the 
nose. 

Diagnosis. — A  history  of  cough  at  night  only  points  to  naso-pharyn- 
geal disease.     As  a  rale  adenoids  and  chronic  tonsillitis  or  phar^Tigitis 


Fig.    133.— Croup  Kettle. 


422  DISEASES   OF   THE   NOSE  AXD   THROAT. 

should  be  suspected.  The  absence  of  fever  and  the  freedom  from  cough 
during  the  day  indicate  a  local  catarrh  which  gravitates  when  the  child 
is  on  its  back. 

Treatment. — If  adenoids  are  present  they  should  be  removed.  Xaso- 
phar}Tigeal  catarrh  should  be  treated  by  local  applications  of  %  per  cent,  of 
iodine  and  glycerine  solution.  The  naso-pharynx  should  be  washed  by 
means  of  a  douche  every  morning  and  evening.  A  weak  solution  of 
boracic  acid  or  bicarbonate  of  soda  is  very  serviceable.  In  persistent 
catarrh  codliver-oil  should  be  given. 

Spasmodic   Cough    (Pseudo-pertussis). 

I  have  previously  described  a  cough  which  occurs  in  children  havmg 
catarrh  of  the  upper  air  passages ;  sometimes  this  night  cough  is  paroxysmal 
in  character  and  the  spasm  resembles  whooping-cough. 

Cause.^ — The  accumulation  of  the  mucus  in  the  region  of  the  arytenoids 
and  the  vocal  cords  sets  up  a  spasm  of  the  glottis,  resulting  in  attacks  of 
suffocation. 

Symptoms. — A  hoarse  or  barking  cough,  appearing  in  spasms  with  an 
interval  of  rest,  is  usually  heard.  The  cough  is  frecjuently  followed  by  vom- 
iting.   The  temperature  is  rarely  above  normal. 

Diagnosis. — The  absence  of  the  cough  by  day  and  the  appearance  of 
the  cough  in  spasms  when  the  infant  is  placed  on  its  back  always  point 
to  a  local  throat  condition  of  a  non-inflammatory  character. 

Treatment. — Eemove  the  cause  if  any  is  apparent.  Locally,  astrin- 
gents are  indicated.  Eestorative  treatment,  consisting  of  iron  and  Fowler's 
solution,  Avill  sometimes  permanently  benefit  the  child. 

Useless  Cough. 

Thompson  and  MacCoy,  of  Philadelphia;  Francis  Warner,  of  London, 
and  Emil  Mayer,  of  ISTew  York,  describe  an  irritating  hacking  cough  in 
children.  Such  children  do  not  suffer  with  fever,  but  have  a  poor  appetite, 
are  thin  and  irritable.  Warner  studied  a  series  of  22,000  children  in 
schools,  and  he  attributes  this  condition  not  to  peripheral  irritation,  in- 
testinal worms,  nor  to  any  disease  of  the  tonsils  or  pharjoix,  but  to  un- 
balanced central  nerve  action. 

Reflex  Cough. 

In  post-nasal  catarrh  we  frequently  have  a  profuse  discharge  which, 
by  irritating  the  pharj^nx,  causes  a  cough.  This  cough  frequently  resembles 
that  of  an  acute  bronchitis.  The  examination  of  the  lungs  in  such  cases 
is  usually  negative.  It  is  therefore  advisable  to  examine  the  nose  and 
throat  in  ever}^  case  of  cough. 


CHAPTER  II. 

DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA, 

The  Lungs. ^ 

The  lungs  in  children  occupy  the  same  position  as  in  adult  life.  The 
trachea  of  the  young  child  is  larger  in  comparison  than  in  the  adult;  so 
also  the  bronchi  are  larger  than.  in.  the  adult.  They  occupy  more  space  and 
are  more  numerous  than  in  the  adult,  but  the  air-cells,  are  much  smaller. 
I  have  described  in  detail  the  method  of  examination  of  the  thorax  in  the 
article  on  "The  Kespiration  in  the  New-born  Baby." 

The  Diaphragm. 

The  diaphragm  occupies  a  higher  position  in  children  than  in  adults. 
Dwight  studied  a  series  of  frozen  sections  and  found  the  diaphragm  in  the 
infant  corresponding  to  the  eighth  and  ninth  dorsal  vertebrse. 

Points  to  be  Noted  in  the  Diagnosis  of  Diseases  of  the  Lungs. 

auscultation. 

Acute  catarrhal  hronchitis :  Sibilant  and  sonorous  rales.  Large  and 
small  bubbling  rales. 

Capillary  bronchitis:    Sibilant,  subcrepitant  rales. 

Asthma:    Sibilant,  wheezing,  sonorous  breathing. 

EvipJiysema:  Eespirations  diminished,  absent,  or  prolonged.  Low- 
pitched  ex'piration. 

(Edema:   Bilateral,  subcrepitant  rales. 

Pneumonia:  (1)  Crepitant  rales;  (2)  bronchial  breathing  and  bron- 
chophony; (3)  broncho-vesicular  breathing,  crepitant,  subcrepitant.  and 
bubbling  rales. 

Pleurisy:  Friction  sound  with  each  respiratory  act,  best  heard  with 
inspiration.  If  the  child  controls  the  movements  of  the  lung  and  keeps 
the  pleural  surfaces  apart,  then  no  friction  sound  is  heard. 

Subacute  pleurisy:  Priction,  absence  of  vesicular  murmur,  and  vocal 
resonance. 

Fluid  and  air  in  pleural  sac:  Respiratory  murmur  absent,  amphoric 
breathing  above,  all  sound  absent  below,  splashing  rales. 


^  Acute  tuberculosis,  tubercular  pneumonia,  and  lobar  pneumonia  are  described 
in  Part  VII,  in  the  "Acute  Infectious  Diseases." 

(423) 


424  DISEASES  OF  THE  BROXC'HI,  LUNGS,  AJSTD  PLEUP^A. 

Tuberculosis:  Long,  high-pitched  expiration,  breathing  feeble,  vocal 
resonance  increased,  adventitious  rales,  later  bronchial  breathing,  bron- 
chophon}^ 

Tuberculosis,  second  stage:  Cavernous  breathing,  amphoric  breathing, 
gurgles,  metallic  echo. 

PERCUSSION  RESONANCE. 

Vesicular:   Uncomplicated  lung. 

Dullness:   Lung  with  increased  proportion  of  solids. 

Flatness:    Solids,  fluids. 

Tympanitic:    Large  body  of  air. 

Vesiculo-tympanitic :   Lung  with  increased  proportion  of  air. 

Amphoric:    Empty  cavity  with  tense  walls. 

CracJied-pot:    Cavity  with  flaccid  walls. 

RHYTHM. 

Normal  rhythm :  Eegular  succession  of  the  respiratory  acts. 
Interrupted  rhythm:    Slight  deposit  in  lung. 
Divided  rhythm:    Want  of  elasticity  in  lung. 
Prolonged  expiration:    Want  of  elasticity  in  lung. 

BREATHING. 

Vesicular:    Uncomplicated  lung. 

Bronchial:    Consolidated  lung;    compressed  lung. 

Broncho-vesicular :    Moderate  consolidation,  moderate  compression. 

Cavernous:   Flaccid  cavity-walls. 

Amphoric:   Tense  cavity- walls. 

Exaggerated:    Vicarious  respiration. 

Diminished:   Plastic  exudation,  want  of  elasticity. 

Absent:   Fluid,  air. 

VOCAL   RESONANCE. 

Normal:    Voice  through  normal  chest. 
Bronchophony:    Voice  through  consolidation. 
Amphoric:  Voice  in  a  cavity. 
JEgophony:   Voice  in  compressed  lung. 
Pectoriloquy:    Articulate  voice  in  cavity;    in  consolidation. 
Whispering  pectoriloquy:    Whispered  articulation  in  cavity;    in  con- 
solidation. 

Cavernous  whisper:    Ill-defined   articulation  in  cavity. 


BRONCHITIS.  425 

BRONCHITIS  (Beonchial  Catarrh ;  Acute  Bronchitis). 

Bronchitis,  commonly  known  as  bronchial  catarrh,  is  one  of  the  most 
frequent  diseases  of  infancy  and  childhood.  It  frequently  follows  nasal 
catarrh,  pharj^ngeal  catarrh,  or  catarrh  extending  from  the  trachea. 

Etiolo^. — There  are  certain  predisposing  factors  which  favor  the 
development  of  this  disease.  Children  with  deficient  nutrition,  suffering 
with  anemia,  and  those  with  a  weakened  framework  having  rickets,  are 
more  susceptible  to  this  disease.  Children  affected  with  catarrh  of  the 
upper  air  passages  frequently  invite  an  extension  of  this  inflammatory 
process. 

Bacteriology. — The  pathogenic  bacteria  found  in  the  bronchi  are  staphy- 
lococci, streptococci,  colon  bacilli,  and  diphtheria  bacilli.  The  bacteria 
most  frequently  seen  are  the  diplococci  of  pneumonia  and  streptococci;  in 
addition  to  these  the  bacillus  of  influenza  frequently  gives  rise  to  bron- 
chitis. Other  germs  found  were  bacillus  pyocyaneus  and  encapsulated  ba- 
cilli. Eitchie^  states  that  the  above  micro-organisms  were  rarely  found 
alone,  but  always  associated.  He  does  not  believe  that  a  definite  germ  is  the 
causative  agent.  These  same  micro-organisms  under  different  conditions 
frequently  enter  the  alveoli  and  produce  pneumonia. 

Pathology. — ^The  anatomical  changes  noted  in  bronchitis  are  the  same, 
irrespective  of  the  cause.  The  disease  may  be  limited  to  the  large  bronchial 
tubes  or  may  extend  into  the  finest  ramifications.  This  tendency  to  extend 
into  the  capillaries  is  greater  in  children  and  still  more  so  in  infants.  The 
accumulation  of  the  catarrhal  products  in  the  smaller  tubes  adds  a  gravity 
of  its  own  to  the  situation.  It  is  well  to  emphasize  this  peculiar  tendency 
of  the  trouble  in  those  of  tender  age.^ 

On  making  a  cross-section  of  the  lung  a  muco-purulent  discharge  oozes 
from  the  bronchi.  The  same  thick  purulent  matter  can  be  forced  out  of 
the  smaller  tubes  when  compressing  the  lung  between  the  fingers.  The 
microscopic  examination  shows  intense  congestion  of  the  superficial  blood- 
vessels. Frequently  there  is  a  serous  infiltration  of  the  bronchial  mucous 
membrane. 

When  the  infection  extends  into  the  smallest  bronchi  it  is  called  "capil- 
lary bronchitis."  Williams  calls  it  "suffocative,"  owing  to  the  severe  symp- 
toms which  develop. 

Capillary  bronchitis  is  always  accompanied  by  some  alveolar  catarrh 
and  frequently  passes  on  to  a  distinct  broncho-pneumonia.  Infectious  secre- 
tions in  the  larger  bronchi  are  sometimes  sucked  into  the  smaller  bronchi 


1  Journal  of  Pathology  and  Bacteriology,  1900,  vii,  1-21. 

2  Christopher:     Article  on  "Bronchitis,"  "American  Text-Book  on  Diseases  of 
Children." 


426  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

and  frequently  cause  an  inflammation  of  the  lobule.  A  plug  of  mucus 
frequently  acts  as  a  valve  in  a  bronchus,  permitting  some  air  to  escape 
during  expiration  and  preventing  the  entrance  of  air  during  inspiration. 

When  all  the  air  is  expelled  the  lobule  may  collapse.  This  condition 
is  known  as  atelectasis  pulmonum.  This  condition  is  favored  when  the 
thorough  expansion  of  the  air  tubes  is  interfered  with.  It  is  also  favored 
by  congestion,  thickening  of  the  mucous  membrane,  and  the  gummy  secre- 
tions produced  by  bronchitis. 

It,  moreover,  accompanies  those  cases  in  which  the  position  is  not  fre- 
quently changed.  It  is  seen  in  rachitic  deformities  of  the  thorax.  The 
most  frequent  place  for  this  condition  is  at  the  border  of  the  lungs.  The 
collapsed  area  is  of  a  dark-red  or  purple  color  and  shows  a  uniform  red 
surface  on  section.  It  sinks  in  water,  but  can  be  insufflated  unless  inflam- 
mation has  already  begun  (Williams). 

Eachford  has  shown  that  disease  of  the  Ij^mphatic  system  is  a  factor 
in  producing  malnutrition  in  children.  In  children  having  the  latter  con- 
dition we  must  not  be  surprised  if  we  have  a  persistent  bronchial  catarrh 
baffling  the  ordinary  method  of  treatment. 

Symptoms  and  Diagnosis. — The  symptoms  vary  with  the  severity  of  the 
disease.  In  mild  cases  the  temperature  rises  to  about  101°  F.  at  night;  in 
severer  cases  the  temperature  will  reach  102°  and  even  103°  F.  The 
respirations  are  quickened  and  labored  and  the  pulse  is  accelerated.  When 
the  temperature  is  subnormal  in  rachitic  children,  then  such  low  temperature 
should  be  looked  upon  as  a  grave  symptom.  On  auscultation  sibilant  rales 
are  heard  anteriorly,  but  more  prominent  posteriorly. 

x^s  the  secretion  from  the  mucous  membrane  begins,  the  sibili  give 
place  to  loose  mucous  rales.  Graves's  point  is  worth  noting,  that  "the 
more  numerous  the  sounds  heard  at  any  one  point  to  which  the  stethoscope 
is  applied,  the  smaller  the  bronchi  involved." 

Much  stress  should  not  be  laid  on  the  sputum  or  the  character  of  the 
expectoration.  Children  under  5  years  rarely  or  never  expectorate.  The 
pulmonic  resonance  is  usually  normal.  If  the  attack  is  a  mild  one,  as  the 
above-named  symptoms  would  seem  to  indicate,  then  the  symptoms  will 
subside  under  palliative  treatment.  The  greatest  attention  should  be  be- 
stowed on  the  pulse. 

A  pulse-rate  between  120  and  130  in  a  young  child  should  be  looked 
upon  favorably.  If  the  pulse  is  suddenly  accelerated  and  reaches  140 
to  160  and  the  respirations  are  increased  to  60  or  80  per  minute,  then  a 
broncho-pneumonia  should  be  suspected.  Bear  in  mind  that  the  normal 
ratio  of  respiration  to  pulse  is  about  1  to  Jfj  when  this  is  disturbed  so  that 
the  ratio  is  1  to  2,  or  even  1  to  3,  we  should  suspect  pneumonia. 

Prognosis. — This  varies  according  to  the  severity  of  the  symptoms  and 
the  condition  of  the  infant  before  it  was  taken  sick.     Children  having  a 


BRONCHITIS.  427 

cachectic  condition  or  those  having  syphilis  will  certainly  have  a  severer 
type  of  infection  than  children  not  so  affected.  In  subnormal  conditions 
bronchitis  will  frequently  leave  some  traces,  so  that  a  "chronic  bronchitis" 
is  established. 

Treatment. — Hygienic  Treatment:  A  child  with  bronchitis  must  be 
put  to  bed  in  a  room  having  a  temperature  of  68°  to  72°  F.  The  air  should 
be  kept  free  from  dust.  The  room  must  be  properly  ventilated.  The  pa- 
tient should  be  given  as  much  sunshine  as  possible.  Dark,  ill-ventilated 
rooms  will  aggravate  this  condition.  The  body  should  be  warmly  clad — 
not  too  warm.  Flannels  should  be  worn  next  to  the  skin.  A  lukewarm 
sponge  bath  followed  by  friction  with  a  coarse  towel  will  stimulate  the 
circulation  and  is  very  grateful  to  the  child.  If  the  child  has  a  high  tem- 
perature then  a  mustard  foot  bath  should  be  ordered. 

Dietetic  Treatment. — If  the  child  takes  a  large  amount  of  nourish- 
ment and  assimilates  the  same,  then  the  chances  of  restoring  health  are 
excellent.  To  rely  on  drugs  and  exclude  food  is  to  discard  the  most  impor- 
tant part  of  the  treatment.  When  the  child  refuses  food  by  mouth,  then 
rectal  feeding  shbuld  be  resorted  to,  so  that  the  body  is  sufficiently  nourished. 
It  is  a  good  plan  to  predigest  milk  for  feeble  infants;  hence  peptonized 
milk  or  whey  and  soups  and  broths  should  not  be  forgotten.  The  yolk  of 
an  egg  beaten  up  with  sherry  wine  for  a  child  several  years  old  will  be 
found  a  convenient  method  for  giving  nourishment  with  stimulation.  Water 
is  very  important  in  the  treatment  of  this  disease,  especially  so  when  there 
is  a  large  amount  of  expectoration. 

Medicinal  Treatment. — If  the  temperature  is  over  102°  F.,  1-drop 
doses  of  tincture  of  aconite,  given  every  two  hours,  will  be  useful  to  reduce 
the  fever.  All  children  who  cough  swallow  their  mucus;  hence  a  laxative 
or  an  emetic  will  be  very  serviceable.  A  teaspoonful  of  castor-oil,  repeated 
in  six  hours,  is  very  valuable.  As  an  emetic  a  teaspoonful  of  syrup  of 
ipecac,  repeated  in  fifteen  or  twenty  minutes  if  necessary,  can  be  tried. 
When  rapid  emesis  is  desired,  1  grain  of  sulphate  of  copper  dissolved  in  a 
teaspoonful  of  water  will  be  very  effective.  This  dose  should  not  be  re- 
peated more  than  once  in  two  or  three  hours.  Apomorphin  in  doses  of 
Vioo  grain,  hypodermically,  is  a  very  effective  emetic.  This  is  indicated 
when  the  child  refuses  to  take  medicine. 

When  the  secretion  is  very  viscid  then  steam  inhalations  will  be  very 
serviceable.  The  steam  atomizer  will  be  found  very  valuable  in  young 
children  who  cannot  be  held  over  moist  vapor.  Steam  impregnated  with 
beechwood  creosote  will  be  found  a  valuable  means  of  loosening  adherent 
mucus.    It  has  a  decided  therapeutic  effect.    It  is  a  powerful  antiseptic. 

Restoi-ative  Treatment. — Eestorative  treatment,  such  as  using  an  emul- 
sion of  codliver-oil  or  a  malt  extract,  with  or  without  iron,  should  not 
be  omitted. 


428  DISEASES   OF  THE   BRONCHI,   LUNGS,   AND  PLEURA. 

Bronchial  Asthma  (Anaphylaxis). 

This  is  frequently  called  spasmodic  asthma,  owing  to  the  spasmodic 
or  paroxysmal  dyspnoea  associated  with  wheezing  respiration.  A  pecul- 
iarity of  this  condition  is  that  children  appear  to  be  perfectly  well  during 
the  interval.    This  is  frequently  an  anaphylactic  phenomenon. 

Etiology. — Children  having  neurotic  tendencies  or  those  children  of 
gouty  families  seem  to  be  predisposed  to  this  affection.  Most  writers  on 
this  subject  believe  that  this  condition  is  a  vasomotor  neurosis  resulting  from 
disturbed  innervation  of  the  pneumo-gastric  or  its  ramifications,  or  the 
vasomotor  nerves,  causing  a  spasm  of  the  muscles  of  the  air  passages.  Hay 
fever  is  an  affection  which  closely  resembles  bronchial  asthma  and  alter- 
nates with  it. 

Exciting  causes  are  many;  for  example,  enlarged  bronchial  glands, 
enlarged  tonsils,  adenoids,  elongated  uvula,  and  hypertrophied  turbinates. 
The  inhalation  of  irritants,  such  as  dust,  may  irritate  and  provoke  a  spasm. 
ISTot  infrequently  we  find  eczema  existing  at  the  same  time  or  alternating 
Avith  attacks  of  asthma. 

Gastro-intestinal  disturbances  are  among  the  most  frequent  causes  of 
asthmatic  attacks. 

In  many  children  various  forms  of  protein,  food,  such  as  white  of  egg 
albumin  or  serum  albumin,  will  give  rise  to  attacks  of  fever,  wheezing  of 
the  chest,  dyspnoea,  and  cyanosis.  That  a  systemic  poison  has  been  intro- 
duced is  very  evident.  This  accounts  for  the  alarming  symptoms  seen  in 
many  children  after  an  injection  of  antitoxin.  This  is  an  anaphylactic 
phenomenon. 

Symptoms. — Without  warning,  a  spasm  or  shortening  of  breath  comes 
on,  most  frequently  at  night.  There  is  usually  such  oppression  and  dis-' 
tressed  breathing  that  the  child  must  sit  up.  Frequently  the  distress  is  so 
great  that  the  child  will  grasp  any  object  within  reach.  The  shoulders  are 
elevated  and  the  head  thrown  back  so  that  the  accessory  muscles  of  respira- 
tion are  brought  into  play.  The  face  assumes  an  anxious  expression,  and 
later  becomes  cyanotic.  The  eyes  are  prominent  and  the  alge  nasi  widely 
dilated.  A  cold,  clammy  perspiration  is  usually  present.  The  respirations 
are  loud  and  wheezing,  and  are  rarely  increased  in  number.  The  inspiration 
is  jerky,  the  expiration  prolonged  and  laborious.  There  is  very  little  or  no 
thoracic  expansion.  The  pulse  is  small  and  rapid.  There  is  no  fever,  but 
we  frequently  have  a  subnormal  temperature  when  the  attack  is  prolonged. 
The  extremities  are  frequently  cold.  After  the  attack  there  is  exhaustion 
followed  by  sleep.  An  attack  may  last  several  hours,  sometimes  days. 
Percussion  of  the  chest  during  the  paroxysm  shows  Jiyperresonance.  There 
may  be  e-ither  diminution  or  prolongation  of  the  vesicular  murmur.  The 
whole  chest  has  sibilant  and  sonorous  rales  and  wheezing  sounds. 


BRONCHO-PNEUMONIA.  429 

The  diagnosis  is  easy ;  we  must  exclude  spasm  of  the  glottis,  croup, 
tracheal  stenosis,  and  neoplasm  in  the  larynx.  The  absence  of  fever  will 
easily  differentiate  this  condition  from  inflammatory  respiratory  diseases. 

The  prognosis  is  usually  good,  especially  so  at  the  time  of  puberty. 
After  an  attack  a  careful  examination  of  the  lungs,  the  kidneys,  the  nose, 
and  the  throat  should  be  made,  and  the  exciting  cause,  if  possible,  should 
be  noted. 

Treatment. — Fresh  air  to  thoroughly  oxygenate  the  lungs  will  afford 
relief.  Do  not  use  steam  or  heat  of  any  kind.  The  application  of  two  or 
three  dry  cups  over  the  front  and  also  over  the  back  of  the  chest  repeated 
every  six  hours  will  relieve  the  spasm.  Surprising  relief  will  be  afforded 
by  washing  the  colon  with  I/2  teaspoonful  of  powdered  ox  gall  in  1  pint  of 
water.  The  latter  will  not  only  empty  the  colon  of  faeces  and  gas,  but  will 
also  relieve  the  mechanical  pressure  on  the  diaphragm.  The  bowels  should 
be  kept  loose  by  giving  salines.  Iodide  of  sodium  in  1-  to  5-  grain  doses 
should  be  given  at  least  one  month  after  the  acute  paroxysmal  attacks  have 
subsided.  Codein,  ^/g  grain  for  a  child  5  years  old,  repeated  every  two 
hours,  or  Dover's  powder,  1-  to  2-  grain  doses,  repeated  every  three  hours 
until  relief  is  afforded.  Chloral  hydrate  with  or  without  bromide  of  sodium 
in  doses  of  3  to  5  grains  once  only  should  be  given  at  night  to  promote 
sleep  and  as  an  antispasmodic. 

The  diet  should  consist  of  milk,  thin  soups,  and  fruit  juices.  All 
starchy  foods,  such  as  potatoes,  bread,  and  cereals,  should  be  omitted. 
After  convalescence,  fruit,  vegetables,  cheese,  fish,  and  meat  may  be  given. 

Broncho-pneumonia  (Catarrhal  Pneumonia  or 
Lobular  Pneumonia). 

This  disease  derives  its  name  from  the  fact  that  it  usually  exists  as 
an  inflammatory  condition  affecting  small  areas  of  the  alveoli  of  the  lung. 
Contrary  to  lobar  pneumonia,  this  catarrhal  form  does  not  terminate  by 
a  distinct  crisis.  This  disease  is  usually  a  sequela  to  or  a  complication  of 
whooping-cough,  measles,  diphtheria,  or  typhoid  fever.  It  is  this  form 
which  is  most  dreaded  in  diphtheria  and  which  rarely  ends  favorably.  It 
does  not  occur  in  distinct  cycles,  nor  does  it  run  a  distinct  course.  One 
child  may  suffer  with  a  broncho-pneumonia  extending  over  ten  days  or 
two  weeks.  Another  child  with  the  same  form. and  severity  of  the  dis- 
ease may  suffer  from  eight  to  ten  weeks.  Thus  this  disease  may  be  con- 
sidered to  be  of  a  distinct  wandering  type.  This  disease  does  not  depend 
on  seasonal  changes,  although  the  greatest  number  of  cases  are  met  with 
in  the  spring  and  fall. 

Etiology.- — By  far  the  greatest  number  of  catarrhal  pneumonias  may 
be  found  in  those  children  offering  the  least  resistance.     Such  cases  are 


430  DISEASES  OF  THE  BRONCHT,  LIANGS,  AND  PLEURA. 

usually  found  in  scrofulous,  tuberculous,  rachitic,  and  syphilitic  children. 
When  children  have  previously  suffered  from  infections  such  as  diphtheria, 
scarlet  fever,  measles,  or  typhoid  fever,  they  are  peculiarly  predisposed  to 
this  secondary  infection.  It  is  for  this  latter  reason  that  this  disease  is  so 
fatal.  In  a  series  of  fatal  cases  accompanying  the  various  types  of  diph- 
theria seen  by  me  at  the  Willard  Parker  Hospital,  the  large  bulk  suc- 
cumbed to  this  complication.  This  is  due  in  a  great  measure  to  the 
devitalized  condition  of  the  body  after  a  toxsemic  infection,  such,  as  is 
foimd  in  diphtheria.  Whether  or  not  this  disease  is  contagious  has  not 
been  definitely  settled. 

Bacteriology. — We  know  that  various  forms  of  germs,  such  as  the 
staphylococcus,  streptococcus,  the  diplococcus  pneumonia  (Friedlander), 
the  diplococcus  (Fraenkel),  and  bacterium  coli,  are  among  the  specific 
micro-organisms  which  have  been  found  intimately  associated  with  this 
disease. 


Fig.  134. — Diplococcus  Pneumoniae  ( Pneumococcus )  :  (a)  single  diplo- 
cocci;  (6)  the  same  in  chains  (Wolf's  double  stain).  Leitz  ocular  I,  oil 
immersion  ^/ij.      (Lenhartz-Brooks.) 

Pathological  Anatomy. — The  tracheal  and  bronchial  mucous  mem- 
brane is  intensely  congested,  and  the  lumen  of  the  smaller  bronchi  filled 
with  thick  muco-pus,  which  adheres  to  the  surfaces  and  is  as  tenacious  as 
a  pseudo-membrane.  The  lung  at  the  seat  of  infection  shows  dark  brown 
or  brownish-red,  infiltrated  areas,  sometimes  of  a  bluish-red  color.  The 
surface  of  the  pleura  contains  large  or  small  hsemorrhagic  areas.  They 
resemble  a  sort  of  hepatization,  brownish,  grayish,  or  yellowish-gray  in 
color,  and  in  some  areas  have  purulent  infiltrations.  Sometimes  the  inter- 
stitial tissue  is  associated  in  this  condition  with  a  tendency  toward  cica- 
tricial formation.  Sometimes  the  alveoli  have  an  emphysematous  disten- 
tion.    The  whole  process  seems  to  be  a  bronchiolitis  associated  with  cir- 


BROXCTIO-PNEUMONIA. 
/ 


431 


Fig.  135. —Purulent  (Suppurative)  Bronchitis,  Peribronchitis  and  Peri- 
bronchial Broncho-pneumonia  in  a  Child  Fifteen  Months  Old.  (a)  Puru- 
lent; (6)  mucoid  bronchial  contents;  {0,0"^)  bronchial  epithelium  infiltrated 
with  round  cells  and  partly  desquamated  (c')  ;  (d)  bronchial  ^Yall  contain- 
ing strongly  congested  blood-vessels  and  infiltrated  with  cells;  (e)  cellular 
infiltrated  peribronchial  and  periarterial  connective  tissue;  (f)  septum  be- 
tween the  lung  alveoli,  partly  infiltrated  with  cells;  {g)  fibrinous  exudate 
in  the  alveoli;  (h)  alveoli  filled  with  richly  cellular,  (i)  with  poorly  cellular 
exudate;  (k)  transverse  section  of  pulmonary  arteries;  (l)^  strongly  con- 
gested bronchial,  peribronchial  and  intra-acinous  vessels.     X  45.      (Ziegler. ) 

cumscribed  atelectasis  of  the  lung,  from  which  hyperaemia  and  infiltrations 
of  tissue  result. 

Symptoms. — The  symptoms  are  those  of  a  bronchial  catarrh  and  a 
bronchitis.  Associated  with  this  there  is  the  usual  fever,  restlessness,  and 
an  increased  frequency  of  respiration;  there  is  also  dyspnoea.  There  is  a 
distinct  cyanosis  affecting  not  only  the  face  and  lips,  but  frequently,  the 
nails.  There  is  an  anxious  expression  to  the  countenance.  The  als  nasi 
participate  in  the  respiration.  The  whole  respiration  seems  to  be  super- 
ficial and  brings  every  muscle  into  action.  That  there  is  an  obstruction 
can  easily  be  seen  by  an  observation  of  the  jugulum,  by  noticing  the  inter- 
costal space  and  also  the  epigastrium,  which  sinks  at  each  inspiration.  The 
frequency  of  respiration  will  sometimes  be  increased  to  70  or  80  per  min- 
ute, and  it  is  very  jerky  in  character.  The  pulse-rate  will  suddenly  rise  to 
140  or  160,  and  frequently  in  some  cases  to  200  per  minute.  The  tem- 
perature may  be  as  low  as  100°  F.  and  gradually  rise  one  degree  or  more 
each  day.    It  may  reach  104°  or  105°  E.  in  the  evening.     The  temperature 


432 


DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


usually  shows  a  morning  remission  of  at  least  one  or  two  and  sometimes 
three  degrees. 

Pictorial  illustrations  of  broncho-pneumonia  complicating  measles  and 
diphtheria  will  be  found  in  their  respective  chapters. 

Physical  Examination. — The  physical  examination  of  the  thorax  shows 
moist  rales,  sibilant  or  sonorous  rales,  or  coarse  mucous  rales,  at  times  dis- 
tinct bronchial  breathing  accompanied  by  a  metallic  sound.  Percussion 
will  usually  show  dullness  over  small  areas.    While  this  may  be  due  to  the 


WILLARD    PARKER    HOSPITAL 


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Fig.  136. — Louis  B.  Aged  3  years.  This  very  instructive  case  illus- 
trates the  tolerance  of  the  larynx  for  the  intubation  tube.  In  all,  twency 
intubations  were  performed.  The  chart  illustrates  the  tube  coughed  up  four 
times  in  one  day,  thus  requiring  four  distinct  intubations  in  twenty-four 
hours.  In  spite  of  the  fact  that  the  case  was  septic  from  the  beginning,  and 
that  the  child  had  a  broncho-pneumonia,  the  ease  recovered.  In  order  to 
retain  the  tube  and  prevent  its  being  coughed  up,  the  caliber  was  gradually 
increased  from  a  number  three  until  an  eleven  to  twelve  tube  was  used. 


localized  area  of  consolidation,  it  is  quite  possible  that  the  dullness  may 
also  be  attributed  to  enlarged  bronchial  glands  in  this  region.  When  the 
disease  terminates  favorably  the  temperature  falls,  the  pulse  assumes  a 
more  regular  character,  the  heart  sounds,  which  formerly  were  feeble,  ap- 
pear louder,  stronger,  and  rhythmic.  The  cough  will  be  more  frequent, 
ihe  respiration  less  frequent  and  not  so  superficial.  Children  who  formerly 
were  apathetic  now  appear  to  notice  everything,  and  appear  very  sensitive 


BRONCHO-PNEUMONIA.  433 

on  bein^  handled,  and  especially  so  during  an  examination.  The  physical 
signs  of  a  dill'used  bronchitis  and  the  ditt'used  areas  of  moist  rales  associated 
with  the  localized  areas  of  bronchial  breathing  disappear.  The  bronchial 
breathing  which  existed  before  now  becomes  vesicular  in  character.  The 
pulse,  which  formerly  was  greatly  accelerated,  and  the  respiration,  which  was 
very  frequent,  now  both  return  to  their  normal  state.  The  whole  character 
of  this  affection  has  no  specific  rule,  but  drags  along  without  a  distinct  terr 
niination,  differing  from  that  condition  so  Avell  knowoi  and  described  as 
croupous  pneumonia.  It  is  not  rare  to  note  an  apparent  cessation  of  the 
inflanmiatory  condition  in  the  pulse,  respiration,  and  temperature,  and  to 
find  that  new  inflammation  has  begun  with  more  active  symptoms  than  has 
been  just  passed  through. 

We  can  therefore  see  that  a  broncho-pneumonia  frequeiitly  is  a  con- 
tinuance of  an  inflammation  which  spreads  from  portion  to  portion  and 
from  lobe  to  lobe,  and  thus  devitalizes  the  system.  The  symptoms  affecting 
the  gastro-intestinal  tract  and  those  of  the  genito-urinaiy  organs  are  the 
same  as  found  in  croupous  pneumonia. 

The  differential  diagnosis  between  catarrhal  and  fibrous  pneumonia  can 
easily  be  made  by  a  comparison  of  the  course  which  these  diseases  run. 
Catarrhal  pneumonia  commences  wdth  symptoms  of  a  bronchial  catarrh  or 
a  bronchitis.  These  same  symptoms  remain  during  the  course  of  the  disease. 
The  symptoms  do  not  have  those  of  an  acute  character  which  characterize 
croupous  pneumonia,  but  rather  assume  a  chronic  appearance.  The  great 
danger  consists  in  the  development  of  pus  infiltration  in  the  lungs,  and 
it  is  only  by  the  rapid  emaciation  that  symptoms  of  miliary  tuberculosis 
can  be  suspected. 

•     We  can  differentiate  catarrhal  pneumonia  from  atalectasis  by  the  total 
absence  of  fever  in  atalectic  conditions. 

Prognosis  and  Course.- — The  prognosis  depends  on  the  origin  of  this 
disease.  If,  for  example,  broncho-pneumonia  is  a  sequela  to  measles,  diph- 
theria, whooping-cough,  scarlet  fever,  or  typhoid,  and  the  child  ]ia^,  passed 
through  a  severe  infection  in  which  the  corpuscular  elements  of  the  blood 
have  greatly  suffered,  then  the  prognosis  is  grave.  If,  on  the  other  hand, 
this  disease  commences  as  a  primary  affection  and  the  child  is  in  a  fairly 
well-nourished  'condition,  then  the  prognosis  is  good.  The  prognosis  will 
chiefly  depend  on  the  amount  of  food  that  can  be  properly  assimilated  and 
the  care  ynilx  which  the  case  is  nursed.  The  course  is  slow  and  tedious, 
and  may  develop  tubercular  pneumonia.  ■■■■-, 

The  hygiene  is  very  ihiportant  in  this  condition.  The  prognosis  of 
catarrhal  pneumonia  following  whooping-cough,  measles,  or  diphtheria  will 
usually  show  that  almost  TO  per  cent,  of  cases  so  affected  are  fatal. 

Treatment. — If  the  temperature  is  high,  antipyretic  reniedi.es,  su<;h  gs 
the  coal-tar  products,  are  not  indicated,  owing  to  their  well-l>nown  de- 


434  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

pressing  effect  upon  the  heart.  The  author  has  never  used  them  without 
seeing  an  ill  effect.  When  they  are  used  they  should  be  combined  with 
camphor  or  musk  to  counteract  this  well-known  depression.  The  safest 
antipyretic  measure  in  pulmonic  affections  is  undoubtedly  hydrotherapy. 
A  cold  compress  applied  over  the  thorax  and  repeated  once  every  half -hour, 
not  only  acts  as  an  antipyretic,  but  will  stimulate  the  respiratory  muscles 
and  provoke  deep  inspirations.  This  will  distend  the  smaller  portions  of 
the  alveoli  and  will  prevent  atalectasis  pulmonum.     If  there  is  very  great 


Fig.    137. — Diagram  lor  Pneumonia  Jacket  Opened  at  Side. 


Fig.    138. — Diagram  for  Pneumonia  Jacket  Opene^  in  Front.      (Original.) 

dyspnoea  owing  to  the  presence  of  viscid  secretions,  then  an  emetic  is  indi- 
cated. One  of  our  best  emetics  is  sulphate  of  copper  in  1-grain  doses,  re- 
peated in  an  hour  if  necessary.  Another  emetic  and  one  which  is  less 
irritating  than  the  above  is  syr.  scillse  comp.  in  I/2  to  1  teaspoonful  doses, 
repeated  every  half-hour  until  the  desired  effect  is  produced.  Syrup  of 
ipecac  in  doses  of  one  teaspoonful,  repeated  every  fifteen  to  twenty  minutes, 
is  also  serviceable.  When  a  child  has  extreme  dyspnoea  and  it  is  not  wise  to 
administer  an  emetic  by  mouth,  then  a  hypodermic  injection  of  V20  grain 
of  apomorphia  dissolved  in  five  or  ten  minims  of  sterile  water  injected 
deeply  into  the  subcutaneous  cellular  tissue  will  usually  provoke  emesis. 
If  this  dose  is  not  effectual  in  fifteen  or  twenty  minutes,  then  another 


BRONCHO-PNEUMOKIA.  435 

dose  of  apomorphia  may  be  given.  Tartar  emetic  in  closes  of  V/,o  grain, 
in  sweetened  water,  may  be  given  every  hour  until  vomiting  is  produced.  It 
is  better  not  to  change  from  one  drug  to  another  unless  several  doses  have 
proven  ineffectual. 

Flaxseed  poultices  are  sometimes  recommended  when  the  secretions 
are  very  viscid.  These  have  frequently  proven  efficacious  in  the  hands 
of  the  author.  In  urgent  dyspnoea  great  relief  can  be  afforded  by  the  appli- 
cation of  dry  cups  over  the  affected  areas  of  the  lungs. 

A  pneumonia  jacket  consisting  of  cheese  cloth,  which  is  worn  next 
to  the  skin,  then  a  layer  of  cotton-wool,  and  the  whole  covered  with  oiled 
silk  or  oiled  muslin  will  serve  to  prevent  chilling  of  the  surface.  Figs. 
137  and  138'  show  diagrams  of  these  jackets. 

Internal  diffusible  stimulations,  such  as  %-grain  doses  of  carbonate 
of  ammonia,  repeated  every  hour,  are  serviceable.  Liq.  ammon.  anisati,  in 
doses  of  from  3  to  10  drops,  repeated  every  hour,  is  one  of  our  best  dif- 
fusible stimulants.  If  symptoms  of  collapse  appear  then  active  alcoholic 
stimulation  must  be  resorted  to,  such,  for  example,  as  champagne,  brandy, 
whisky,  or  wine  ad  lihitum.  In  addition'  thereto,  a  sinapism  over  the  front 
and  back  of  the  chest  and  mustard  foot  baths  may  be  required.  Hypo- 
dermic medication  will  frequently  be  found  necessary,  especially  if  the 
heart's  action  is  feeble.  One  two-hundredth  of  a  grain  of  nitro-glycerine 
injected  hypodermically  or  caffeine  citrate  will  sometimes  work  well. 
Strychnine  sulphate  in  doses  of  ^/goo  grain,  gradually  increased,  repeated 
every  three  or  four  hours  or  oftener,  will  stimulate  the  heart's  action.  An 
excellent  heart  stimulant  is  to  give  1  drop  of  tincture  of  musk  every  hour. 

If  the  cough  is  very  troublesome,  especially  at  night,  and  the  child  is 
in  a  fair  physical  condition,  then  codeine  in  doses  of  ^/oq  to  ^/k,  grain  for 
a  child  1  year  old,  repeated  every  two  or  three  hours,  will  relieve.  Dionin  is 
a  remedy  that  has  been  used  by  the  writer  with  considerable  success  in  the 
treatment  of  various  forms  of  cough  in  doses  of  ^/^o  grain,  repeated  every 
three  or  four  hours,  for  a  child  1  year  old. 

Stimulating  expectorants  such  as  syrup  of  senega,  in  doses  of  from  10 
to  15  minims,  may  be  advantageous.  The  vital  point  to  remember  is  to 
support  the  system  with  nourishment.  If  the  child  will  not  take  food 
per  mouth,  then  rectal  feeding  consisting  of  nutrient  enemas  is  demanded. 

Water  should  be  given  freely  during  the  course  of  a  broncho-pneumonia 
to  stimulate  the  action  of  the  kidneys. 

Pleukisy. 

An  inflammation  of  the  pleura  is  by  no  means  rare  in  children.  It 
is  found  very  frequently  post-mortem,  although  no  evidence  of  the  same 
existed  intra  vitam.    It  may  be  a  primary  condition. 

There  are  two  distinct  forms  of  pleurisy  usually  seen:     1.  Pleuritis 


436 


DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


sicca  (dry  pleurisy).  2,  Pleuritis  exudativa.  The  latter  form. can  .again 
be  divided  into  (a)  serous^  (&)  sero-purulent,  (c)  purulent^,  (d)  lisemor- 
rhagic. 

The  last  mentioned  is  a  rare  condition.  It  is  seen  in  traumatic  con- 
ditions, in  haemophilia,  and  occasionally  when  tuberculosis,  is  present. 

Dey  Pleurisy. 

This  form  of  pleurisy  usually  follows  an  exposure  to  cold,  although 
it  may  follow  as  a  secondary  inflammation  to  the  lung.  There  is  usually 
an  exudation  of  fibrin  only. 


^a\\o\\^\^e.O^'b^ 


Fig.  139. — Fever  Curve  in  a  Case  of  Dry  Pleurisy.      (Original.) 


Pathology. — The  pleura  is  swollen  and  thickened,  and  there  is  an  exu- 
dation of  fibrin.  Adhesions  frequently  result  from  these  bands  of  fibrin 
between  the  opposite  ^pleural  surfaces.  The  pleura  loses  its  natural  luster. 
When  the  process  ceases  and  the  lymph  is  absorbed,  the  condition  is  called 
"dry  pleurisy."  The,, fibrinous  bands  between  the  pleura  costalis  and  pul- 
monalis  usually  leave  permanent  adhesions. 

Symptoms. — The  disease  is  usually  ushered  in  with  high  fever,  which 
may  reach  104°'  or  105°  F.  Cough  is  usually  present.  It  is  a  short,  hack- 
ing, irritating  cough.  It  is  accompanied  with  pain.  As  a  rule,  children  cry 
during  each  coughing  paroxysm.  A  characteristic  symptom  often  noted  is 
that  a  child  suffering  with  pleurisy  usually  places  its  hand  over  the  affected 
area  during  a  coughing  paroxysm.  This  lends  support  to  the  ribs  and 
relieves  pain.  There  is  no  expectoration.  A  friction  sound  or  a  fine,  crepi- 
tant rale  is  heard  over  the  affected  area.    There  is  vesicular  breathing.    The 


I'LKL'KISV  WITH  KFKLSIUN.  437 

percussion  is  rarely  abnormal.  The  tongue  is  usually  coated.  The  bowels 
are  constipated.  The  urine  is  scanty.  The  surface  of  the  body  is  dry  and 
warm.  There  is  usually  a  gradual  increasing  dyspncea.  The  pulse-rate 
is  increased;  so  also  are  the  respirations.  The  symptoms  resemble  those 
of  a  pneumonia  and  can  rarely  be  differentiated  without  a  careful  physical 
examination.  There  is  usually  pain  on  percussion  over  the  affected  area. 
The  children  do  not  wish  to  be  handled,  but  prefer  to  lie  quietly. 

The  dia^osis  depends  on  the  symptoms  above  described.  We  must 
bear  in  mind  the  frequency  with  which  pulmonary  complications  are  asso- 
ciated. 

The  prognosis  is  usually  good,  although  adhesions  frequently  remain. 

Treatment. — Counter-irritation,  such  as  cupping  of  the  chest,  the 
application  of  iodine  over  the  affected  area,  or  painting  with  cantharidal 
collodion,  acts  well.  Strapping  the  chest  with  broad  straps  of  adhesive 
plaster  or  the  application  of  a  very  tight  fitting  bandage  seems  to  sup- 
port the  chest  and  relieve  the  cough.  Calomel  is  indicated,  especially  if 
constipation  accompanies  this  condition.  Iodide  of  sodium,  with  very  small 
doses  of  codeine,  may  be  given  at  regular  intervals  to  relieve  pain.  A  full 
dose  of  codeine  or  morphine  may  be  given  at  night  if  the  cough  is  distress- 
ing or  the  pain  acute.  I  have  given  from  Vso  to  ^/oo  grain  of  morphine 
hypodermically  to  a  child  3  years  old  to  relieve  a  severe  cough. 


Pleupisy  with  Effusion  (Pleuritis  Exudativa). 

This  secondary  form  of  pleurisy  is  usually  a  complication  or  an  exten- 
sion of  the-  infection  in  pneumonia.  It  is  frequently  met  with  in  influenza 
and  in  infectious  diseases.  I  have  frequently  seen  pleurisy  with  effusion 
in  the  scarlet  fever  wards  of  the  Eiverside  Hospital.  I  have  also  seen  pleu- 
risy complicating  tuberculosis  and  rheumatism  in  children. 

Bacteriology. — In  some  cases  the  streptococcus,  in  others  the  staphy- 
lococcus, is  present.  A  diplococcus  has  also  been  found  and  believed  by 
some  to  be  the  cause  of  pleuritis.  The  pneumococcus  has  been  found  pres- 
ent, so  that  it  is  difficult  to  state  which  pathogenic  microbe  is  the  true  cause 
of  this  condition.  Whether  this  microbe  gains  entrance  to  the  pleura  from 
the  lung  by  inhalation  or  through  the  skin,  or  whether  the  tonsil  is  the 
means  of  entrance  of  the  pathogenic  bacteria  causing  this  disease,  has  not 
been  definitely  determined.  We  know  that  suppuration  in  other  parts  of 
the  body,  as,  for  example,  in  the  abdomen  or  in  the  spine,  can  frequently 
carry  microbic  elements  to  the  pleura  and  thus  directly  transmit  the  infec- 
tion. Pyogenic  bacteria  may  be  carried  to  the  pleura  through  the  lymph 
channels  and  by  the  circulation. 

,^  -  Pathology. — This  form  of  exudative  pleurisy  is  the  one  most  frequently 
encountered.     We  rarely  find  both  sides  involved,  although  a  double  pleu- 


488 


DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 


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Fig.    140. — Fever  Curve  in  a  Case  of  Pleurisy 
with  EflFusion.     (Original.) 


risy  is  by  no  means  rare.  The  pathological  condition  is  practically  the  same 
as  described  in  the  chapter  on  "Dry  Pleurisy."  In  this  condition  we  have 
more  or  less  serous  effusion.  The  serum  may  be  clear,  it  may  be  bloody,  or 
it  may  be  turbid.  Serous  effusions  found  in  a  healthy  child  are  usually 
absorbed.    Adhesions  are  frequently  left  in  this  form  of  pleurisy. 

Symptoms. — The  fever 
may  be  high  or  low.  Fever 
and  general  malaise  accom- 
panied by  a  hacking  cough 
will  frequently  be  the 
only  symptoms.  I  have 
frequently  seen  children 
brought  to  my  clinic  with 
the  history  of  a  cougli,  no 
expectoration^  anorexia,  with 
general  weakness  and  ema- 
ciation, in  whom  a  pleurisy 
with  a  large  effusion  was 
detected. 

Diagnosis. — The  diag- 
nosis in  very  young  children 
is  at  times  difficult.  It  can 
only  be  made  by  a  most  careful  physical  examination  of  the  chest. 

Physical  Signs. — Before  the  effusion  is  marked,  and  during  its  absorp- 
tion friction  sounds  are  heard  over  the  inflamed  area.  After  the  effusion 
is  present  there  are  no  friction  sounds.  There  are  an  absence  of  rales,  dis- 
tant bronchial  breathing,  and  flatness  on  percussion.  There  is  diminished 
breathing,  so  that  the  voice  or  the  cry  of  the  child  will  appear  very  distant. 
At  the  level  of  the  fluid  the  voice  has  a  tremulous  sound,  known  as 
cegophony.  There  is  a  bulging  of  the  intercostal  spaces.  The  breathing  is 
bronchial  or  tubular.  Not  infrequently  the  heart  is  displaced.  A  careful 
inspection  of  the  chest  will  show  that  there  is  a  loss  of  motion  on  the 
affected  side  during  respiration. 

In  some  cases  the  diagnosis  depends  on  the  result  of  an  exploratory 
puncture  with  a  clean  (aseptic)  needle  having  a  large  caliber.  One  of  the 
best  needles  for  this  purpose  is  one  similar  to  that  used  for  the  injection 
of  antitoxin.  A  puncture  should  be  made  after  washing  the  skin  with 
soap  and  water  followed  by  alcohol  or  ether.  The  needle  is  then  inserted 
about  one  inch.  Sometimes  it  is  necessary  to  make  several  exploratory 
punctures  in  order  to  find  the  liquid,  especially  so  in  the  encapsulated  form 
of  pleurisy,  where  a  small  area  is  involved.  After  withdrawing  the  liquid 
the  character  of  the  same  should  be  determined  by  examining  it  under  the 
microscope.    If  pus  corpuscles  are  found  we  should  insist  on  an  operation. 


EMPYEMA. 


439 


as  no  other  Ireatnicnt  will  be  satisfactory.  Not  infrequently  a  serous  effu- 
sion will  be  al)sorbe(l  by  the  exploratory  puncture,  so  that  the  puncture  is  at 
times  a  very  valuable  therapeutic  adjunct. 

Treatment. — Firm  strapping  of  the  chest  with  bands  of  adhesive 
plaster  is  useful;  5-  to  15-  grain  doses  of  iodide  of  sodium,  according  to 
age,  may  be  administered  three  times  a  day  in  milk,  soup,  or  broth.  Fresh 
air  should  be  constantly  permitted.  If  pain  is  absent  gentle,  but  long 
inspirations  and  expirations  (pulmonary  gymnastics)  are  worth  trying. 
By  properly  exercising  the  lungs  we  can  stimulate  nutrition  to  the  parts 
and  frequently  assist  in  the  absorption  of  an  effusion. 


Fig.  141. — Diagrammatic  Illustration  of  Heart  and  Lungs  in  a  Left- 
sided  Pleuritic  Effusion,  a.  Heart,  h.  Compressed  lung,  area  of  bronchial 
breathing  and  crepitant  rales,     c.  Effusion.     (Original.) 


Dietetic  Treatment. — N"o  matter  what  form  of  treatment  is  instituted, 
nothing  will  avail  so  much  as  proper  feeding.  The  dairy  products — milk, 
eggs,  and  cheese — in  conjunction  with  cereals  and  fruits,  should  form  the 
bulk  of  the  food  ordered.     Concentrated  soups  and  broths  are  also  useful. 


Empyema  (Purulent  Pleurisy). 

Etiology. — As  a  rule  we  find  this  disease  following  pneumonia  or  pleu- 
risy. It  18  a  favorite  complication  of  the  infectious  diseases,  so  that  after 
a  pneumonia  in  an  acute  infectious  disease  we  must  not  be  surprised  to  find 
an  empyema. 


440'  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

'..::■•. Bacteriology. — The  bacteria  most  frequently  found  are  the  strepto- 
coccus; the  staphylococcus,  and  the  pneumococcus.  Earely  has  the  tubercle 
bacillus  been  found. 

-  Pathology. — The  surface  of  the  pleura  is  covered  with  fibrin  and  pus 
and  the  cavity  filled  with  a  purulent  exudate,  the  result  of  this  inflamma- 
tio'H;:''"  The  piis  settles  to  the  bottom  of  the  pleural  sac. 

::.  ■■  Not  infrequently  both  pleurae  become  involved,  although  the  rule  is 
to  find  but  one  pleura  or  part  of  it  affected.  When  not  treated  the  pus  may 
rupture. into  the  Inng  or  burrow  externally  through  an  intercostal  space. 

Symptoms. — The  most  pronounced  symptoms  are  flatness  on  percussion 
and  diminished  respiratory  sounds.  Sometimes  they  are  totally  absent. 
There  is  also  a  loss  of  the  vocal  fremitus.  At  the  level  of  the  fluid  the  voice 
has  a  tremulous  quality  known  as  cegophony. 

Above  the  fluid  the  breathing  is  broncho-vesicular  due  to  the  com- 
pressed lung.    Pleurothotonos  is  sometimes  seen. 

There  is  an  absence  of  expansion  of  the  chest  on  the  affected  side. 
When  this  condition  exists,  on  the  left  side  it  may  displace  the  heart. 

/  rely  upon  the  examination  of  the  hlood,  in.  addition  to  the  physical 
signs  given,  as  an  important  guid.e-'in  determining  the  presence  of  pus  in  the 
system..  See.':  article  and  illustration  of  "Blood  Reaction  of  Pus"  in  the 
chapter  on  "BloO^d." 

Diagnosis. — ilf  the  fever  continues  after  a  ease  of  pneumonia,  or  pain 
in  the  chest  persists  accompanied  by  dypsnoea,  cough,  and  sweats,  then 
empyema  should  be  suspected. 

W^hen  the  disease  progresses  the  temperature  frequently  returns  to 
normal  or  nearly  so.  The  child  shows  symptoms  of  general  exhaustion, 
emaciation,  and  is  extremely  anemic.  Diarrhoea  is  a  frequent  sym.ptom  in 
this  condition. 

.Th-e  physical  signs  above  noted  are  usually  positive.  AVhen  there  is 
any  idoubt,  and  in  order  to  confirm  the  sj^mptoms  pointing  to  an  empyema, 
an  exploratory  puncture  should  be  made. 

If  the  needle  is  sterile  and  sharp  and  the  surface  to  be  punctured  is 
rendered-aseptic,  then  there  is  no  risk  in  making  one  or  more  punctures  to 
aid  in^ establishing  the  diagnosis. 

,  •;,  Choice  as  to  Where  the  Needle  is  to  he  Introduced. — My  plan  has  always 
been  -to  find  by  percussion  the  area  having  the  greatest  dullness  or  flatness, 
and  insert  the  needle  after  noting  the  following : — 

Points  to  he  Noted  ivhile  Making  an  Exploratory  Puncture. — The  skin 
should  be  washed  with  soap  and  water,  dried,  and  again  washed  with  alcohol, 
and  lastly  with  ether;  The  needle  should  be  boiled  about  five  minutes  before 
being  used. 

; ,;:.  I|  the  needle  is  introduced  on  the  right  side,  due  allowance  must  be 
made  for  dullness  in  the  region  occupied  by  the  liver.     Do  not  introduce. 


EMPYEMA. 


441 


the  needle  too  near  the  region  of  the  spine,  l)ut  choose  rather  an  intercostal 
space  in  the  axillary  line  or  preferahly  below  the  scapula  on  either  side. 
If  the  needle  is  introduced  on  the  left  side  do  not  push  it  too  forcibly  nor 
too  deeply  or  hfeniorrhage  may  result.  Sometimes  the  fluid  is  fibrinous  and 
will  not  readily  enter  the  caliber  of  the  needle.  If  the  needle  is  plunged 
too  far  and  enters  a  dilated  bronchus,  due  jillovvance  must  be  made  for  a 
purulent  seciction.  wliich  slioidd  not  bo  niisliikcn  lor  oni[)y('ma. 


Fig.  142. — Illustrating  a  Severe  Localized,  Right-sided  Empyema.  Two 
ribs  were  resected. _  The  child  made  a  complete  recovery.  The  thorax  shows 
very  slight  deformity  after  the  operation.      (Original.) 


Prognosis. — ^I'his  depends  upon  the  general  condition  at  the  time  of 
the  operation.  If  the  tubercle  bacillus  is  found  in  the  pus  the  prognosis  is 
bad.  The  longer  the  disease  existed  the  more  doubtful  the  prognosis.  If 
the  condition  is  a  sequela  to  a  pneumonia  or  a  pleurisy  then  the  prognosis 
is  good. 

Course. — The  tendency  of  empyema  in  a  child  is  to  recovery.  Out  of 
20  cases  operated  by  me,  18  recovered  in  four  to  five  weeks.  One  case 
recovered  after  six  months  of  continued  surgical  treatment,  and  was  op- 
erated three  times.  One  case  was  ill  over  tw^o  years,  tubercle  bacilli  being 
found.    This  case  belonged  to  the  tuberculous  type  of  empyema. 


443  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

Surgical  Treatment. — When  pus  is  located,  the  indication  is  to  remove 
it.  After  painting  the  area  with  tincture  of  iodine  an  incision  should  be 
made  at  least  two  inches  long  through  the  skin,  and  parallel  with  the  rib. 
If  the  pus  is  thin  in  character  a  simple  intercostal  incision  carried  into  the 
pleura  will  evacuate  the  same.  If  the  pus  contains  fibrinous  coagula,  it  is 
better  to  resect  one  or  two  ribs.  Care  must  be  taken  to  preserve  the 
periosteum  in  resecting  the  ribs.  By  this  latter  method  we  have  complete 
drainage,  and  if  the  case  is  treated  on  general  aseptic  principles  with 
drainage,  gauze,  and  restorative  treatment,  the  outcome  is  usually  good. 

Points  to  be  noted  in  empyema  cases : — 

1.  Ancesthetic. — Do  not  use  general  anaesthesia  if  cyanosis,  marked 
dyspnoea,  or  other  severe  toxic  symptoms  are  present. 

Local  angesthesia,  such  as  chloride  of  ethyl  or  cocaine,  can  be  used. 
I  have  frequently  operated  with  the  aid  of  chloride  of  ethyl. 

2.  Regarding  Antisepsis. — When  pus  is  located  we  must  resort  to  the 
usual  details  of  asepsis  and  antisepsis.  The  instruments  should  be  rendered 
thoroughly  aseptic  and  the  child  should  be  given  a  bath  on  the  day  of 
operation  in  addition  to  a  thorough  scrubbing  of  the  seat  of  operation. 

The  physician,  if  a  general  practitioner,  should  not  operate  if  he  has 
been  in  contact  with  an  acute  infectious  case;  neither  should  he  operate  if 
he  has  a  case  of  erysipelas  or  diphtheria  under  his  care. 

While  pus  is  being  evacuated,  turn  the  child  from  side  to  side,  to  empty 
the  pleural  cavity.    If  the  heart's  action  is  poor  this  should  not  be  done. 

A  large-sized  drainage  tube  should  be  inserted  into  the  wound.  The 
pleural  cavity  should  not  be  washed  with  any  fluid.  It  is  important  to  have 
a  cross-section  of  rubber  tube  or  a  large  safety  pin  attached  to  the  drain- 
age tube ;  otherwise,  as  has  already  happened,  the  tube  may  be  lost  in  the 
cavity. 

Excepting  when  large  coagula  are  present,  as  in  pneumococcus  empyema, 
the  syphon  drainage  (Kenyon  method)  may  be  recommended.  This  form 
of  drainage  is  especially  indicated  in  streptococcus  empyema;  however,  this 
type  is  extremely  rare  in  children. 

A  male  child,  4  years  old,  was  brought  to  my  office  by  Dr.  M.  Freid,  with  the 
following  clinical  history:  The  child's  appetite  is  poor.  He  does  not  sleep  well,  and 
has  a  peculiar  waddling  gait.  The  left  shoulder  blade  protrudes  so  that  a  decided 
deformity  is  noticeable.    There  was  no  further  history. 

An  examination  of  the  child  showed  marked  emaciation.  Temperature  lOOVs" 
F.,  pulse  120,  respiration  38,  breathing  labored,  heart  sounds  weak  but  clear.  On 
percussion  there  was  marked  dullness  and  flatness  over  the  central  and  upper  lobe 
of  the  lung  on  the  left  side.  An  exploratory  puncture  made  about  the  eighth  inter- 
costal space  showed  pus.  Owing  to  the  weakened  state  of  the  child,  it  was 
necessary  to  operate  without  an  anfesthetic.  Ethyl  chloride  was  used,  an  incision 
made,  and  two  ribs  resected.  Thorough  drainage  was  maintained  with  the  aid  of  a 
drainage  tube,  and,  with  the  addition  of  restorative  treatment,  the  case  made  an 
uneventful  recovery. 


CHRONIC  EMPYEMA. 


44:} 


Treatment. — The  treatment  consists  in  building  up  the  system  with 
tonics  of  iron,  hypophosphites,  codliver-oi],  malt,  sea-salt  bathing,  and 
fresh  air,  in  addition  to  a  nutritious  diet,  of  which  milk,  eggs,  and  cereals 
should  form  the  bulk. 

Stimulation  will  be  urgently  required.  In  other  words,  our  aim  should 
be  to  build  up  the  body  to  withstand  the  shock  of  the  operation,  and  at  the 
same  time  to  nourish  and  restore  the  general  weakened  condition. 

After-treatment. — Strict  asepsis.  Change  dressings  daily.  Use  clean 
drainage  tube  and  fresh  gauze.  Eemember  the  danger  of  iodoform  poison- 
ing in  using  large  strips  of  iodoform  gauze. 

Give  nutritious  food.  Sometimes  a  change  of  air  to  the  mountain?  or 
seashore  will  aid  in  recovery. 


Fig.    14.3. — James  Apparatus  for  Expanding  the  Lungs  in  Empyema. 

Eemember  that  10  per  cent,  of  all  cases  in  which  a  simple  incision 
is  made  do  not  require  after-treatment.  Ninety  per  cent,  of  cases  require 
resection  of  the  ribs  and  frequently  additional  surgical  treatment  for  chronic 
empyema. 

James  Apparatus. — Pulmonary  gymnastics,  such  as  inspiration  and 
expiration,  should  be  frequently  practised  to  aid  in  the  expansion  of  the 
iung  after  an  operation  for  empyema.  A  clever  device  is  known  as  the 
James  apparatus,  by  which  a  colored  liquid  can  be  blown  from  one  bottle 
into  another.  This  may  be  given  to  the  child  as  a  toy,  and  is  very  valuable 
as  a  means  of  producing  deep  inspiration  and  expiration. 


Chronic  Empyema. 

Neglected  cases  or  those  of  long  standing  frequently  require  additional 
treatment.  Adhesions  will  frequently  form,  preventing  the  normal  expan- 
sion of  the  lung.  A  small  opening  or  sinus  containing  exuberant  granula- 
tions will  be  seen.  In  some  cases  seen  by  me  pus  has  oozed  for  months.  In 
a  case  of  this  kind  nothing  will  do  as  well  as  a  radical  operation  such  as 


444  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

Estlander  recommended  (thoracoplasty).  The  adhesions  must  be  broken 
up  and  thorough  drainage  allowed.  When  such  a  radical  operation  is  per- 
formed, deformity  usually  follows.    These  cases  belong  to  the  surgeon. 

TUBERCULAK    EMPYEMA. 

This  condition,  while  rare,  has  been  seen  by  me  twice  during  the  last 
five  years.  It  is  found  in  families  where  tuberculosis  exists.  We  must 
bear  in  mind  that  a  tubercular  empyema  may  be  the  complication  of  what 
was  formerly  a  non-tubercular  type. 

Environment  and  heredity  play  an  important  part  in  the  etiology  of 
this  condition.  Just  as  a  tuberculosis  may  follow  the  broncho-pneumonia 
of  measles,  so  I  believe  that  tubercular  empyema  may  also  develop.  The 
following  case  will  illustrate  this  condition  as  seen  by  me  in  consultation 
in  New  York  City: — ■ 

M.  J.,  5  years  old,  ^Yas  referred  to  be  by  Dr.  Mehreiilander,  with  a  history  of 
cough,  fever,  and  emaciation.  The  diagnosis  of  empyema  was  made  and  an 
exploratory  puncture  showed  the  presence  of  pus.  With  the  assistance  of  Dr. 
Mehrenlander  I  performed  a  thoracotomy.  As  there  were  thick,  croupous  masses, 
two  ribs  were  resected  and  a  drainage  tube  inserted.  In  this  case  the  wound 
discharged  several  months  and  an  examination  of  the  pus  showed  the  presence  of 
tubercle  bacilli.  With  the  aid  of  fresh  air  and  restoratives,  such  as  codliver-oil, 
creosote  carbonate,  and  special  attention  to  the  out-door  life,  the  child  recovered. 

Family  History. — The  child's  father  and  mother  are  living.  Their  occupation 
is  janitor  and  janitress  in  a  tenement,  house.  They  receive  in  compensation  for 
services  free  rent,  so  that  gives  them  very  unsanitary  surroundings.  The  bedrooms 
are  dark  and  very  unsanitary.  An  older  brother,  17  years  of  age,  has  acute  apical 
tuberculosis.  This  older  brother  when  brought  to  me  for  a  slight  cough  showed 
no  visible  evidence  of  disease;  in  fact,  he  appeared  well  nourished.  His  sputum  con- 
tained tubercle  bacilli.  We  therefore  have  in  the  two  cases  just  described  a  tuber- 
cular empyema  associated  with  family  tuberculosis.  The  coexistence  of  empyema  and 
a  family  history  of  tuberculosis  strengthened  my  opinion  that,  living  under  the  same 
unsanitary  conditions  and  associating  together,  these  cases  were  most  probably 
transmitted  or  communicated. 

The  excellent  results  which  have  been  reported  during  the  last  few 
years  by  the  treatment  with  an  artificial  pneumothorax,  and  the  injections 
of  nitrogen,  lend  encouragement  in  the  treatment  of  this  fatal  disease.  Erom 
my  own  experience  I  strongly  favor  this  method  in  every  case  in  which 
tuberculosis  exists. 


PART  VII. 

THE  INFECTIOUS  DISEASES. 


CHAPTKiJ  1, 


FEVER.' 

This  is  a  pathological  process  generally  caused  by  the  poisonous  prod- 
ucts of  bacteria,  and  characterized  by  a  rise  of  temperature  above  the  limit 
of  the  daily  variation.  It  is  further  associated  with  an  increase  in  the  fre- 
quency of  the  heart  and  the  respiratory  movements,  often  with  an  increase 
in  excretion  of  urea  and  ammonia  in  the  urine  and  a  diminution  in  the 
•alkalies  and  CO2  in  the  blood. - 

Some  authors  state  that  the  cause  of  fever  is  the  action  of  bacterial 
poison  or  of  other  substances  on  the  heat  centers,  and  that  antipyretics  or 
drugs  which  reduce  the  temperature  in  fever,  do  so  by  restoring  the  centers 
to  their  normal  state  by  preventing  the  development  of  the  poisons,  aiding 
their  elimination,  or  antagonizing  their  action.  Thus  it  has  been  stated 
(supporting  the  latter  view)  that  if  the  basal  ganglia  have  been  cut  off 
(by  section  of  the  pons)  from  their  lower  nervous  connections,  fever  is  no 
longer  produced  by  injection  of  cultures  of  bacteria  which  readily  cause  it 
in  an  intact  animal — while  antipyrine  has  no  influence  on  the  temperature. 
These  experiments  were  reported  by  Sawadowski. 

Some  observers  have  been  unable  to  find  any  clear  evidence  of  heat 
centers ;  that  is,  of  localized  portions  of  the  central  nervous  system  specially 
concerned  in  the  regulation  of  the  body  temperature. 

It  is  almost  certain  that  some  pyrogenic  or  fever-producing  agent — 
cocaine,  for  example — acts  indirectly  through  the  brain  or  cord,  and  likely 
others  affect  directly  the  activity  of  the  tissues  in  general,  just  as  -some 
antip3Tetics  or  fever-reducing  agents,  such  as  quinine,  seem  to  act  imme- 
diately upon  the  heat-forming  tissues,  while  antipyrine  affects  them  through 
the  nervous  system. 

Variations  in  Temperature.^ — The  temperature  of  the  body  is  not  con- 
stant. It  varies  with  the  time  of  day,  with  eating,  with  age,  somewhat 
with  violent  changes  in  the  external  temperature  (hot  or  cold  baths),  and 
even  possibly  with  sex. 


'  For  treatment  of  fever,  see  pages  474  and  475. 

-Stewart's  Physiologj-.   p.  44,*^.      Article  on  "Animal  Heat." 

'The  temperature  as  a  diagnostic  aid  is  described  in  Part  I,  page  11. 

(445) 


446  THE  INFECTIOUS  DISEASES. 

The  lowest  temperature  is  recorded  between  2  and  6  a.m.  The  highest 
at  5  to  8  P.M.  There  is  a  corresponding  fluctuation  of  pulse-rate  at  the  same 
time  of  day. 

Taking  of  food  increases  the  temperature,  but  not  more  than  one-half 
of  a  degree  in  healthy  individuals.  Entrance  of  food  into  the  body  in- 
creases metabolic  activity,  no  doubt  through  entrance  of  products  of  diges- 
tion into  the  blood. 

Sex. — Females  usually  have  higher  temperature  than  males. 

Relation  of  Age  to  Temperature. — There  is  a  relative  imperfection 
between  heat  regulation  in  old  people  and  young  children;  thus,  young 
children  are  more  liable  to  sudden  increase  in  temperature  as  well  as  to 
chills.  A  fit  of  crying  will  send  up  the  temperature.  Sudden  fright  (slam- 
ming a  door)  will  send  up  the  temperature  (J.  L.  Smith). 

Mosso  reports  that  the  rectal  temperature  rose  three  degrees  in  a  dog 
rendered  helpless  with  injections  of  curare.  When  injections  of  strychnine 
were  given,  this  latter  (strychnine)  no  doubt  irritated  the  nervous  system. 
He  found  that  the  presence  of  food  was  enough  to  cause  the  rise  in  the 
temperature  of  the  dog. 

Thus  we  find  that  the  usual  fever-causing  factors  are : — 

1.  Toxins. 

2.  Ferments. 

3.  Products  of  waste  which  are  absorbed  in  the  lymphatics  (detritus). 

We  know  that  the  regulation  of  the  heat  is  brought  about  by  the  cen- 
tral nervous  system,  and  we  also  know  the  influence  brought  about  by  the 
vasomotor  (nervous)  system  in  dilating  and  contracting  the  capillaries. 

The  discovery  of  Aronsohn  and  Sachs,  that  by  traumatism  or  irritation 
of  the  corpus  striatum,  an  elevation  of  temperature  is  produced,  is  still 
a  question,  doubted  by  many  distiiiguished  observers.  But  it  certainly 
does  look  as  though  a  certain  center  or  centers  exist  which  influence  the 
body  temperature. 

Knowing  then  that  other  agencies  besides  disease '  cause  an  elevated 
temperature,  the  question  arises :  Are  we  justified  in  designating  every  rise 
of  temperature  as  "fever"?  Hardly.  An  elevation  of  temperature  (above 
normal)  should  be  designated  as  "hyperthermia."  We  know  that  the 
fever  is  caused  by  the  absorption  of  infectious  products  which  later  cause 
a  breaking  down  and  loss  of  the  red  blood-corpuscles,  breaking  down  of  the 
tissues,  and  disintegration  of  albumin  and  its  compounds,  and  produce 
symptoms  pointing  to  distinct  disorders  in  the  human  economy.  Some 
authors  have  described  fever  under  two  headings  or  divisions : — 

1.  Septic. 

2.  Aseptic. 

As  an  example  of  a  septic  fever,  we  have  that  chronic  poisoning  of  the 
human  organism  which  takes  place  in  chronic  pulmonary  tuberculosis,  and 


FEVER.  447 

even  in  this  latter  toxaemic  process  we  find  sudden  rises  of  temperature, 
which  must  be  explained  by  emotional  means,  or  rather  by  nervous  causes. 
In  a  tuberculous  patient  whose  system  is  overwhelmed  with  toxins  (chronic 
and  continuous  poisoning)  we  can  readily  understand  why  the  thermic 
centers  as  well  as  all  other  centers  could  be  easily  influenced  to  cause  a 
sudden  rise  in  temperature  responding  to  a  slight  emotion  or  fright. 

Let  us  now  consider  so-called  "nervous"  or,  as  it  has  been  designated, 
"hysterical  fever."  The  latter  term  we  owe  to  the  French  authors  (Pomme, 
Toussot,  Baillon,  Eiviere).  By  this  we  mean  a  febrile  condition  which  is 
not  caused  by  any  inflammatory  or  other  disease  agency,  and  which  is 
found  in  either  very  nervous,  neurasthenic,  or  hysterical  patients. 

Broussois  (France)  opposed  this  theory  and  believed  this  condition 
due  chiefly  to  inflammatory  changes  in  the  ovary  and  uterus. 

Briquet  showed  by  careful  examination  the  fallacy  of  the  foregoing 
statements  in  a  series  of  noteworthy  investigations. 

In  1888  Chaveau,  in  Paris,  wrote  a  careful  dissertation  called  "Fievre 
Hysterique,"  and  divided  this  condition  into  several  distinct  groups.  A 
characteristic  point  is  the  absence  of  gastric  disturbance  (digestive),  show- 
ing that  it  was  not  a  malignant  disturbance. 

Chaveau  looked  to  the  cause  of  his  cases  in  an  abnormal  excitation  of 
the  thermic  center  in  sensitive  (nervous)  individuals.  An  accompanying 
factor  he  believes  to  be  either  traumatic  or  psychic  disturbances. 

Wunderlich  (Germany)  long  ago  called  attention  to  the  fact  that 
hysteria  influences  the  temperature,  and  that  in  hysterical  neurosis  we  find 
sudden  elevations  of  temperature.  It  is  a  remarkable  fact  and  one  noted 
by  many  others  that  one  side  of  the  body  shows  this  high  temperature 
without  any  pathological  condition  manifesting  itself. 

Rosenthal  (Vienna)  found  distinct  localized  areas  of  redness  with 
marked  rise  of  temperature  in  this  area,  but  found  no  general  febrile 
disturbance.  The  patient  was  decidedly  hysterical.  Strumpell  agrees  that 
he  has  found  very  high  temperatures,  irregularly,  but  believes  the  patients 
simulated  their  marked  hysterical  and  irritable  condition. 

Ewald  (Berlin)  agrees  that  hysterical  patients  can  produce  high  fever 
by  reason  of  their  excitement. 

Hale  White  (England)  doubts  that  the  thermogenetic  functions  should 
cause  high  fever,  and  cites  instances  which  were  known  as  hysterical 
paralysis. 

Cleman  reported  in  the  Clinical  Society  of  London,  1883,  a  case  of 
hysterical  fever  showing  the  enormous  temperature  of  111°  F.  at  various 
times. 

Hale  White  believed  that  a  mistake  in  reading  the  thermometer  was 
made. 


448 


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450  THE  INFECTIOUS  DISEASES. 

Ughetti  believes  hysterical  fevers  exist,  and  cites,  as  proof  of  the  same, 
fever  in  course  of  hysteria,  chorea,  epilepsy,  and  Basedow's  disease. 

The  greatest  scientific  contribution  on  this  subject  has  certainly  been 
the  work  of  A.  Sarbo  in  the  University  of  Psychiatrie  and  Nervous  Dis- 
eases in  Budapest.^  He  believes  as  a  result  of  experimental  study  that 
the  causation  of  fever  should  be  looked  forward  to  in  the  "central  nervous 
system,''  and  that  the  experimental  discoveries  of  the  thermic  and  vaso- 
motor centers  seem  to  confirm  this.  This  author  believes  that  fever  which 
has  no  organic  lesion  as  a  cause  should  be  called  functional  fever,  which 
is  a  condition  found  in  hysteria,  the  latter  a  functional  neurosis.  It  is 
interesting  to  record  that  Debone  increased  the  temperature  by  suggestion 
to  101.2°  F.,  or  38.5°  C. 

Krafft-Ebing  records  temperatures  by  suggestion  as  high  as  106.4°  F. 

Sarbo  concludes  by  saying  that  from  his  clinical  observations  a  distinct 
hysterical  fever  exists. 

Hysterical  fever  can  simulate  by  its  exacerbation  and  remission  such 
diseases  as  typhoid,  malaria,  tuberculosis,  and  meningitis. 

Some  years  ago  much  was  expected  from  the  antipyretic  drugs — antl- 
pyrin,  acetanilid,  and  phenacetin;  and  if  it  could  have  been  shown  that 
they  distinctly  improved  the  condition  of  the  fevered  patient  it  would  have 
been  a  strong  argument  against  the  view  that  pyrexia  is  a  defensive  mech- 
anism. 

When  fever  arises  and  a  distinct  diagnosis  cannot  be  made,  the  child 
should  be  put  on  the  expectant  plan  of  treatmerd.  This  will  consist  in 
cleansing  the  gastro-intestinal  tract,  regulating  the  diet,  and  noting  symp- 
toms as  they  arise.'  This  is  especially  indicated  when  we  believe  the  case 
to  be,  in  the  period  of  incubation,  of  an  infectious  disease.  At  such  times 
the  following  recipe  is  a  good  antipyretic  and  will  not  depress  the  heart : — 

IJ   Sweet  spirit  of  niter    1%  flui drachms 

Citrate  of   potassium    30  grains 

Syrup  of  lemon    4  fluidrachms 

Aquse    q.    s.   ad     2   fluidounees 

A  teaspoonful  every  three  hours,  for  child  1  year  old, 

I  am  indebted  to  Dr.  William  H.  Guilfoy,  Eegistrar  of  the  New  York 
Health  Department,  for  many  courtesies  in  the  preparation  of  the  statis- 
tics of  the  various  infectious  diseases. 

Bacterial  Vaccines.^ 

The  vaccine  treatment  of  disease  in  children  has  many  advocates. 
There  are  very  many  instances  in  which  specific  results  may  be  attained ;  on 


^Published  in  the  Archiv  fiir  Psychiatrie  in  1891. 

^  These  vaccines  are  prepared  in  the  Sherman  laboratories  of  Detroit,  and  in 
the  Mulford  laboratories  of  Philadelphia. 


BACTERIAL  VACCINES.  45 1 

the  otiier  hand,  we  should  not  be  disappointed  when  we  meet  with  failures. 
The  following  class  of  cases  lend  themselves  to  this  form  of  treatment: — 

How  to  Procure  an  Autogenous  Vaccine. — Clean  the  surface  of  the  skin 
with  alcohol  or  tincture  of  iodine.  Make  a  small  incision  with  a  sterile 
bistoury  into  the  furuncle  and  remove  1  drop  of  pus,  to  inoculate  the 
surface  of  a  blood-serum  culture  tube.  Send  to  a  laboratory  to  be  placed  in 
an  incubator.  From  thirty-six  to  forty-eight  hours'  time  is  required  to 
have  a  vaccine  made. 

Stock  Vaccine. — If  too  remote  from  a  laboratory,  a  stock  vaccine  of  the 
staphylococcus  variety  may  be  used  with  excellent  results. 

Local  infections,  as  well  as  general  systemic  infections  with  fever,  do 
not  contraindicate  the  use  of  these  vaccines.  They  may  be  injected  regard- 
less of  the  temperature.  Surgical  treatment,  and  general  systemic  treatment 
of  the  bowels,  kidneys,  etc.,  should  be  continued  just  as  though  no  vaccine 
had  been  used. 

Streptococcus  infections  from  the  pleural  cavity,  as  in  empyema,  or  from 
the  middle  ear  in  acute  otitis  have  been  treated  with  vaccines. 

The  consensus  of  opinion  found  amongst  competent  clinical  observers^ 
is  that  the  streptococcus  vaccine  has  not  the  specific  virtues,  nor  does  the 
vaccine  give  the  same  benefit,  obtained  from  the  staphylococcus  vaccine. 

An  injection  of  50,000,000  to  500,000,000  dead  bacteria  is  usually 
given.  Of  all  vaccine  therapy,  the  most  brilliant  results  have  been  obtained 
with  autogenous  vaccines  or  stock  vaccine  of  staphylococci;  hence,  in  those 
diseases  which  owe  their  origin  to  a  staphylococcus,  vaccines  should  be  used. 

In  chronic  suppurative  processes  in  which  subnormal  conditions  prevail, 
vaccine  therapy  will  stimulate  j)hagocytosis  and  thus  aid  in  restoring  normal 
conditions. 

In  multiple  fnrunculosis,  in  acne,  and  in  otitis  media  due  to  the 
staphylococcus,  vaccine  should  be  used.  In  post-operative  emp3-ema  with 
low  vitality  and  tendency  to  run  a  long  course,  vaccine  therapy  is  iiidicated. 
In  suppuration  of  the  antrum  of  Highmore,  or  in  recurring  styes  caused  l)y 
staphylococci,  vaccine  therapy  should  be  used. 

An  injection  of  50,000,000  bacteria  constitutes  the  initial  dose.  The 
part  is  cleansed  by  tincture  of  iodine,  and  the  injection  given  subcutaneously. 
Another  injection  of  50,000,000  bacteria  should  be  given  after  three  to  five 
days,  and  if  no  improvement  is  noted  at  the  end  of  ten  days,  then  a  third 
injection  of  100,000,000  bacteria  should  be  given. 

General  Furunculosis. — ^A  child  10  years  of  age  was  brought  to  my 
office  with  a  series  of  furuncles  that  required  incision.  They  healed  after 
four  or  five  days.  Then  new  ones  appeared.  Surgical  treatment  was  re- 
quired.   In  all,  over  a  dozen  had  developed.    I  decided  to  have  an  autogenous 


^  Howlaiul  and  Hoobler,  Archives  of  Pediatrics,  Sept.,  1910. 


452  THE  INFECTIOUS  DISEASES. 

vaccine  made.  The  pns  was  examined  and  proved  to  be  staphylococcus 
pyogenes  aureus.  An  injection  of  a  vaccine  containing  500,000;,000  bacteria 
was  given.  These  injections  were  repeated  every  other  day  until  five  were 
given.  The  child  quickly  recovered.  These  injections  checked  the  develop- 
ment of  new  furuncles. 

Gronococcus  Vaccine. — Injections  of  50,000,00  to  100,000,000  bacteria 
of  the  gonococcus  vaccine  have  been  given  by  me  daily  until  ten  injections 
were  given.  No  systemic  reaction  followed.  The  discharge  lessened  in 
some  cases,  it  disappeared  in  others.     The  gonococcus  however  persisted. 

Typhoid  Vaccine. — An  injection  of  25,000,000  typhoid  bacilli  may  be 
given  to  a  child,  and  repeated  in  one  week,  unless  a  severe  reaction  is  noted. 
If  fever  occurs,  wait  ten  days  to  two  weeks  before  giving  the  second  injec- 
tion. A  third  injection  of  50,000,000  bacteria  should  be  given  ten  days 
after  the  reaction  following  the  second  injection  has  subsided. 

Pertussis. — I  have  had  excellent  results  with'  the  vaccine  made  from 
cultures  of  the  Bordet-Gengou  bacillus,  by  the  Health  Department  of  New 
York  City.^  As  a  prophylactic  three  subcutaneous  injections  are  usually 
given,  one  every  third  day.  Children,  500  million,  1000  million  and  2000 
million;  adults,  1000  million,  2000  million  and  3000  million. 

For  curative  purposes,  four  to  five  injections  are  usually  given,  one 
every  second  or  third  day.  Children  under  one  year  should  receive  250 
million,  500  million,  1000  million,  1500  million,  2000  million.  Children 
over  1  year,  500  million,  1000  million,  2000  million  and  repeat  last  dose.  As 
a  rule  this  is  sufficient,  but,  if  no  result  is  obtained,  further  injections  may 
be  tried  as  well  as  larger  doses. 

A  local  reaction  may  occur  and  is  without  significance,  disappearing  in 
24  hours.  A  general  reaction,  which  is  rare,  would  indicate  that  the  inter- 
vals between  injection  should  be  lengthened  and  dose  more  gradually 
increased. 

Erysipelas  Vaccine. — ^My  results  with  vaccine  treatment  in  erysipelas 
are  excellent.  I  have  seen  a  severe  erysipelas  improve  after  an  injection  of 
50,000,000  bacteria  the  first  day,  75,000,000  the  second  day,  and  100,000,000 
the  third  day.  In  profound  toxemia  with  temperature  ranging  between  103 
and  105  degrees  I  have  injected  from  50,000,000  to  100,000,000  bacteria  of 
the  erysipelas  vaccine  in  an  infant  1  year  old.^  The  dose  was  repeated 
every  other  day.     Five  doses  in  all  were  given. 

Streptococcus  Tonsillitis. — G-ive  an  injection  of  50,000,000  bacteria. 
If  no  reaction  follows,  repeat  the  dose  on  the  following  day.  If  no  improve- 
ment is  noted,  give  100,000,000  bacteria  on  the  third  day. 


^Vaccine  furnished  by  the  courtesy  of  Dr.  Krumwied. 
^  See  clinical  case  in  article  on  Erysipelas. 


BACTERIAL  VACCINES. 


453 


B-abies  Vaccine. — The  Pasteur  treatment  has  now  been  simplified  and 
can  be  administered  at  home  by  simple  vaccine  injections.  When  a  child 
has  been  bitten  by  a  dog,  no  time  should  be  lost,  but  the  treatment  imme- 
diately begun.  The  daily  dose  for  injection  is  contained  in  an  ampule.  The 
treatment  should  be  continued  for  twenty-one  days. 

The  New  York  Health  Department  sends  out  treatment  by  mail  to 
physicians  for  their  own  patients.    Full  directions  are  sent  in  the  mailing 


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case.  One-fourth  of  1  per  cent,  of  carbolic  acid  is  added  to  the  emulsion 
prepared  as  above  for*  the  first  three  days'  treatment,  20  per  cent,  glycerin 
is  added  to  all  other  emulsions.  The  carbolic  and  glycerin  are  added  as 
preservatives  and  are  omitted'  when  the  vaccine  is  administered  to  patients 
at  the  laboratory. 

The  Hygienic  Laboratory  at  Washington  also  sends  treatments  by  mail 
and  a  half-dozen  manufacturing  firms  have  followed  suit.  The  results  from 
the  treatments  sent  seem  to  be  equally  as  good  as  those  from  the  treatments 
administered  at  the  laboratory. 


454  THE   INFECTIOUS   DISEASES. 

Vaccine  Treatment  of  Pneumonia. — Literature  records  many  cases  of 
pneumonia  in  which  marked  improvement  followed  one  or  more  injec- 
tions of  pneumococcus  vaccine.  My  own  experience  with  the  vaccine  has 
been  good.  I  have  used  the  heterogeneous  variety,  although  in  many  cases 
an  autogenous  vaccine  may  be  preferred.  To  procure  an  autogenous  vaccine 
there  are  several  difficulties  encountered:  Pirst,  the  difficulty  of  procuring 
sputum  from  a  child.  Second,  the  time  lost  in  waiting  for  a  blood  culture 
to  grow,  and  then  the  preparation  of  a  vaccine  from  the  blood  culture.  This 
usually  takes  several  days.  When  it  is  important  to  have  an  immediate 
effect,  the  stock  vaccine  should  be  used. 

In  the  sputum  there  may  be  found  the  pneumococcus  and  the  strepto- 
coccus. Frequently  the  streptococcus,  staphylococcus,  and  influenza  bacillus 
are  found.  Because  of  this  mixed  infection,  the  pure  pneumococcus  vaccine 
alone  does  not  exert  the  specifxC  influence  that  we  might  expect  from  it. 

During  the  winter  of  1914  I  had  occasion  to  see  two  unusually  severe 
types  of  pneumonia.  In  one  case  an  infant  13  months  old  received  an  in- 
jection of  1  cubic  centimeter  of  the  mixed  influenza,  pneumococcus,  and 
streptococcus  vaccine.  The  disease  undoubtedly  was  cut  short ;  the  tempera- 
ture dropped  from  105°  F.  to  normal  in  three  days.  The  physical  signs 
gradually  disappeared.  Convalescence  was  undoubtedly  hastened  by  the 
use  of  the  vaccine. 

A  second  child,  3%  years  old,  began  with  a  severe  influenza  affecting 
the  nose  and  throat,  and  follicular  tonsillitis.  The  inflammatory  condition 
extended  and  a  broncho-piieumonia  was  discovered  seven  days  after  the 
onset.  In  this  case  an  injection  of  1  cubic  centimeter  of  the  mixed  pneumo- 
coccus, streptococcus,  and  influenza  bacillus  was  given.  As  no  distinct 
improvement  was  noted,  a  second  injection  was  given,  twenty-four  hours 
later,  after  which  decided  improvement  was  noted.  The  disease  terminated 
by  lysis.    The  child  recovered.     (See  temperature  chart.  Fig.  144.) 

Vaccine  treatment  is  especially  indicated  when  fever  is  prolonged  and 
resistance  is  poor.  A  marked  leucocytosis  usually  follows  these  injections, 
thus  proving  that  more  resistance  is  given  to  the  patient  by  such  injection. 


CHAPTER  II. 

PERTUSSIS    (WHOOPING-COUGH). 

Tins  acute  infectious  disease  is  caused  by  a  specific  micro-organism. 

Etiolog^y. — The  catarrhal  type  of  child  with  hypertrophic  tonsils,  and 
especially  the  child  with  adenoid  vegetations,  is  more  susceptible  to  whoop- 
ing-cough. When  the  cervical  lymph-glands  are  enlarged,  due  to  an  in- 
fection of  the  lymphatics,  then  this  disease  will  enter  more  readily.  The 
tuberculous  child  and  the  syphilitic  child  will  offer  less  resistance  to  this 
disease  than  the  normal  child. 

Poor  hygienic  surroundings,  and  living  in  congested  districts,  where 
sunlight  and  fresh  air  are  wanting,  are  factors  that  encourage  the  develop- 
ment of  this  infectious  disease.  Statistics  have  proven  that  a  child  arti- 
ficially fed  will  take  this  infection  quicker  than  an  infant  brought  up  on 
human  milk. 

Bacteriology. — In  1906  iBordet  and  Gengou  isolated  a  bacillus  from 
the  sputmn  of  whooping-cough  patients,  but  the  complications  of  this  disease 
are  due  to  a  mixed  infection.  Mallory  and  Hover^  demonstrated  that  in 
pertussis  there  is  a  large  accumulation  of  bacilli  between  the  cilia  of  the 
respiratory  epithelium,  this  interference  with  normal  bacillary  action  hinder- 
ing removal  of  inhaled  particles,  and  thus  depriving  the  lungs  of  their  most 
effective  means  of  resisting  invading  bacteria. 

The  Complement-Deviation  Test. — A.  Friedlander  and  E.  A.  Wagner- 
state  that  the  diagnosis  can  be  made  in  the  catarrhal,  the  paroxysmal,  or  the 
convalescent  stages. 

Technique  of  Test. — A  small  amount  of  blood — about  15  to  20  drops — 
are  taken  from  the  patient's  ear,  finger,  or  toe  in  small  test-tubes,  or  in 
the  Wright  capillary  tubes.  For  young  children  the  great  toe  is  very  satis- 
factory. The  blood  is  kept  at  room  temperature,  or  placed  in  the  in- 
cubator until  coagulation  has  taken  place.  Serum  is  then  separated  more 
completely  from  the  clot  in  the  centrifuge.  So  far  in  the  tests  only  fresh, 
active  serum  has  been  used.    Two  drops  of  the  serum  were  used  in  each  test. 

Hemolytic  System. — The  Nogmchi  system  was  used  because  of  its  ex- 
treme delicacy,  and  because  of  the  small  amounts  of  material,  especially 
serum,  required.  In  this  system  washed  human  corpuscles,  1  drop  to  4 
cubic  centimeters  of  salt  water  were  used. 

Amboceptors. — ^The  amboceptors  employed  were  prepared  according 
to  the  ISToguchi  method,  the  serum  being  dried  on  filter-paper.     The  com- 


^  Journal  of  Medical  Research,  Nov.,   1912. 
Amer.  Jour,  of  Dis.  of  Children,  August,   1914. 

(455) 


456  THE   INFECTIOUS  DISEASES. 

plement  was  obtained  in  the  usual  way  from  guinea-pig  dilution  1  to  40. 
Aside  from  the  delicacy  of  this  hemolytic  system,  it  is  of  great  value  in 
working  with  children  because  of  the  very  small  quantity  of  blood  required. 
It  is  not  necessary  to  "take  blood  from  the  veins,  and  the  small  quantity  of 
blood  required  is  easily  obtained  even  from  very  young  infants. 

Antigen. — ^This  is  the  most  important  factor  in  the  test.  Subcultures 
were  made  on  Borders  medium  and  on  ascitic  fluid  agar  exclusively  and 
the  antigens  were  made  as  follows :  Seventy-two  hour  growths  were  taken. 
The  colonies,  which  were  very  tenaciousi,  were  scraped  off  the  agar  with  a 
glass  hook  into  sterile  salt  water.  An  emulsion  was  made  and  the  bacteria 
again  washed  in  salt  water.  It  is  important  to  do  the  second  washing  so 
as  to  rid  the  emulsion  of  any  particles  of  agar.  From  this  washed  emulsion 
a  standard  suspension  was  made,  and  0.1  to  0.2  cubic  centimeters  of  this 
used  in  the  tests.    Throughout  the  test  live  bacteria  were  used. 

Controls. — In  each  test  known  normal  and  known  positive  controls  were 
used.  In  each  series  of  tests  the  hemolytic  system  was  tried  out  in  the 
usual  manner,  using  a  water  bath  at  37°  C.  for  incubation.  After  primary 
incubation  for  half  an  hour  the  amount  of  amboceptor  indicated  by  the 
preliminary  test  was  added  to  our  final  test-tubes  and  the  tubes  again 
incubated  in  the  Avater-bath. 

In  18  cases  tested  during  the  paroxysmal  stage  all  gave  positive  re- 
actions.   The  reaction  is  not  present  in  bronchitis. 

Diagnosis. — ^There  are  three  stages  to  this  disease :  first,  the  catarrhal 
stage;  second,  the  paroxysmal  or  spasmodic  stage;  third,  the  stage  of  decline. 

In  the  catarrhal  stage  we  are  dealing  with  the  symptoms  of  an  irritant 
cough,  with  no  fever,  no  vomiting,  and  very,  little  expectoration.  Such 
expectoration  is  of  a  glistening  or  glairy  character.  The  cough  is  severe  at 
night,  and  milder  during  the  day.  As  a  rule,  the  appetite  is  poor,  and  the 
child  shows  nervous  symptoms,  such  as  irritability  by  day  and  restlessness  at 
night.  In  some  cases  there  is  an  intestinal  catarrh  associated,  and  the  stool 
contains  shreds  of  mucus. 

In  the  spasmodic  stage,  usually  the  second  or  third  week  after  an  in- 
fection, the  cough  appears  in  spasms  and  ends  in  a  "whoop."  The  cough 
is  usually  linked  together  and  followed  by  a  long  inspiration  which  has, a 
distinct  "whoop."  During  this  coughing  paroxysm  the  face  assumes  a 
reddish  or  cyanotic  appearance.  Many  paroxysms  end  in  vomiting.  Violent 
paroxysms  frequently  cause  nose-bleeding  or  hsemoptysis.  When  the 
paroxysms  have  continued  for  a  week  or  more,  the  face  assumes  a  characteris- 
tic puffy  appearance.  An  intense  capillary  congestion  will  frequently  be 
seen  on  the  skin  and  also  by  an  examination  of  the  conjunctival  mucous 
membrane. 

The  paroxysmal  stage  may  last  from  four  to  ten  weeks,  although  I 
have  seen  severe  cases  in  which  a  distinct  "whoop"  continued  for  six  months. 


PERTUSSIS    (WHOOriNG-COUGH).  457 

It  is  a  good  plan  to  count  the  number  of  paroxysms  in  twenty-four  hours, 
and  by  comparison  with  the  previous  week  we  can  judge  of  improvement,  if 
the  frequency  of  the  spasm  is  lessened.  Not  infrequently  30  to  50  paroxysms 
may  occur  in  twenty-four  hours. 

During  a  severe  paroxysm,  the  forcible  pushing  forward  of  the  tongue 
stretches  the  frenum  and  brings  it  into  contact  with  the  teeth,  frequently 
resulting  in  ulceration. 

The  symptoms  of  the  third  stage,  or  stage  of  decline,  correspond  to 
those  of  the  first  stage,  although  there  is  extreme  exhaustion  from  the  force 
and  frequency  of  the  cough.  From  the  inanition  due  to  the  vomiting  and 
the  loss  of  sleep  caused  by  the  paroxysmal  cough,  cardiac  weakness  must  be 
expected.  The  heart  sounds  are  feeble  and  muffled.  A  systolic  blowing 
murmur  is  usually  heard  at  the  apex  and  may  remain  for  many  months. 
The  pulse  is  small,  low  tension,  and  frequently  irregular,  owing  to  the  heart 
strain.  Owing  to  the  disturbance  of  the  circulation,  in  addition  to  the 
inanition,  cold  extremities  are  usually  not'ed^ 

Differential  Diagnosis. — In  the  early  stage  of  pertussis  it  is  quite  diffi- 
cult to  differentiate  it  from  bronchitis.  An  examination  of  the  blood  should 
be  made,  and  if  a  marked  13'mphocytosis  is  present  then  the  diagnosis  is 
positive.  If  the  cough  is  paroxysmal  in  character  and  most  frequent  at 
night,  we  should  suspect  pertussis. 

The  frequency  of  the  cough  and  the  intensity  of  the  spasm,  which  grows 
worse  from  day  to  day,  is  characteristic  of  whooping-cough.  When  a  child 
with  pertussis  is  taken  into  the  fresh  air  the  spasms  as  a  rule  are  less  marked. 

If  after  exposure  to  a  case  of  whooping-cough,  fourteen  days  have 
elapsed,  and  no  cough  has  developed,  we  can  consider  the  child  free  from 
infection. 

In  New  York  City  children  suffering  from  whooping-cough  are  ex- 
cluded from  school  until  the  whoop  has  entirely  disappeared,  which, 
generally  speaking,  means  from  six  weeks  to  two  months. 

Complications. — The  most  frequent  complication  seen  by  me  is  broncho- 
pneumonia. The  prolonged  duration  of  the  cough  and  the  broncho- 
pneumonia frequently  end  in  tuberculosis.  Pleurisy  with  or  without 
effusion  is  occasionally  encountered.  Atelectasis  involving  one  or  more 
lobes  of  the  lung  is  occasionally  seen  in  rickety  children.  The  heart  suffers 
because  it  is  subjected  to  a  severe  strain.  An  irregular  or  intermitting 
pulse  may  frequently  be  noted  because  of  the  exhaustion  from  the  frequency 
of  the  spells,  the  inanition  resulting  from  vomiting,  and  the  loss  of  sleep 
due  to  the  cough.  Emphysema  is  occasionally  met  with.  Asphyxia  is  one 
of  the  dangers  during  continued  paroxysms.  When  convulsions  occur 
during  the  course  of  this  disease  the  outcome  is  usually  fatal.  Paral5'sis 
has  been  described  after  a  severe  paroxysm.  Such  paralysis  may  be  due  to 
an  intracranial  haemorrhage.     The  frequency  of  hemorrhage  from  violent 


458  THE  INFECTIOUS  DISEASES. 

coughing  paroxysms  is  one  of  the  great  dangers  of  this  disease.  Epistaxis  is 
quite  common.  The  sclera  of  both  eyes  is  the  seat  of  frequent  hasmorrhages. 
Hsemoptysis  and  hsematemesis  are  frequently  noted.  Cerebral  haemor- 
rhage resulting  in  unilateral  or  bilateral  paralysis  is  occasionally  met  with. 
Hemiplegia  or  paraplegia  following  pertussis  must  be  looked  upon  as  a  very 
grave  complication,  although  not  necessarily  fatal.  Strabismus  has  been 
reported  in  this  disease  following  a  severe  cerebral  haemorrhage.  Loss  of 
vision  and  partial  or  complete  aphasia  have  been  reported.  Hsematuria  with 
and  without  nephritis  is  occasionally  met  with  during  the  course  of  this 
disease.  The  functional  derangement  of  the  kidneys  may  be  due  to  the 
long  duration  of  the  disease.  Diabetes  mellitus  has  been  seen  by  me  which 
persisted  more  than  two  years. 

Prognosis  and  Course. — The  outcome  of  any  case  depends  on  three 
factors:  First,  the  proper  nutrition  of  the  body  by  frequent  feeding.  If 
food  is  ejected,  then  more  food  must  be  given.  Second,  the  amount  of  rest 
obtained  to  restore  the  exhaustion  from  the  violent  coughing.  Third,  the 
prevention,  if  possible,  of  complications.  If  complications  exist,  such  as  an 
empyema,  treatment  should  be  instituted  as  though  it  were  not  a  case  of 
pertussis. 

The  course  of  the  disease  can  be  shortened  by  supporting  the  strength 
of  the  body  with  food  and  by  aiding  nature  in  securing  rest  at  night. 

Treatment. — Medicinal:  There  is  no  specific  in  the  treatment  of  this 
disease.  Phenacetin  2  to  5  grains,  or  antipyrin  in  the  same  dosage,  re- 
peated every  two  hours  until  relief  is  afforded,  will  modify  the  cough.  For 
relief  at  night  codein  should  be  given  liberally ;  %  grain  gradually  increased 
to  14  grain  may  be  given  to  a  child  2  to  5  years  old,  and  repeated  every  two 
to  three  hours  until  the  cough  lessens.  Cautiously  given,  the  dose  of  codein 
may  gradually  be  increased  u.ntil  %  to  %  grain  per  dose  is  given.  No 
systemic  disturbance  will  be  noted. 

Another  valuable  drug  is  sulphate  of  morphia ;  no  more  than  ^/so  grain 
increased  to  Vie  grain  should  be  given  every  four  hours  to  a  child  2  to  5 
years  old.  Great  care  should  be  exercised  and  the  nurse  invariably  cautioned 
regarding  the  dangers  of  this  drug. 

Heroin  in  doses  of  V24  grain  increased  to  V12  or  %  grain,  may  be 
repeated  every  four  hours,  in  some  palatable  menstruum  like  syrup  of  Tolu, 

If  sleep  is  disturbed  and  the  cough  is  severe,  5  to  10  grains  of  sodium 
bromide  combined  with  2  to  3  grains  of  chloral  hydrate  may  be  repeated 
every  three  hours. 

Tussol,  phenocoll,  lactophenin,  euchinine,  paLsterin,  and  antispasmin 
are  drugs  recommended  by  enthusiasts.  They  have  been  tried  by  me  with 
indifferent  results;  in  some  cases  they  are  of  value,  but  in  most  cases  useless. 

Fischl,  of  Prag,  strongly  advises  the  inunction  of  antitussin  by  thor- 
ough massage  into  the  thorax.    This  remedy  owes  its  therapeutic  value  to  the 


PERTUSSIS    (WHOOPING-COUGH).  459 

presence  of  fluorin  vapors  which  are  liberated.  In  addition  thereto  he 
recommends  the  oil  of  cypress,  this  aromatic  oil  to  be  dropped  on  the  pillow 
at  night,  or  on  gauze  worn  around  the  neck  by  day. 

Bromoform  has  served  in  very  many  cases,  sometimes  with  marked 
benefit ;  in  other  cases  no  benefit  was  noted.  The  dose  of  bromoform  is  from 
2  to  5  drops  in  syrup,  three  times  a  day.  Belladonna  and  atropin  have 
their  advocates.  Owing  to  the  extreme  dryness  and  the  erythematous  flush 
following  the  administration  of  belladonna,  it  must  be  used  with  caution. 
My  results  do  not  warrant  recommending  the  same.  Dionin  (Merck),  in 
doses  of  V50  to  V25  grain  cautiously  increased,  may  be  given  every  three 
hours  to  a  2-year-old  child. 

To  relieve  the  distress  caused  by  the  coughing  paroxysms,  an  abdominal 
support,  very  snug  fitting,  affords  relief.  In  like  manner  a  plaster  bandage 
snugly  applied  around  the  ribs  will  give  additional  support  to  the  thorax 
and  frequently  modify  intense  paroxysms.  Strips  of  belladonna  plaster  en- 
circling the  chest  may  do  some  good.  Such  plaster  may  be  left  in  position 
from  several  days  to  one  week. 

The  injection  of  a  vaccine  prepared  from  the  Bordet  bacillus  made 
by  Dr.  G.  H.  Sherman  has  many  advocates. 

Fresh  Air. — The  spasms  can  be  shortened  by  keeping  the  child  in  the 
open  air;  the  roof  is  the  best  place  in  a  city.  Such  open-air  treatment  to 
be  continued  night  and  day  during  the  mild  weather.  During  stormy 
weather  the  windows  should  be  kept  wdde  open.  In  winter  with  the  body 
properly  clad  the  fresh,  cool  air  will  do  more  to  restore  the  child's  health 
than  all  drugs  combined. 

Food. — During  the  spasmodic  stage  the  child's  nutrition  is  lessened 
because  of  the  frequent  vomit.  Small  meals  at  frequent  intervals  are  indi- 
cated. Yolk  of  egg  in  milk  or  orange  juice,  calf's  foot  or  chicken  jelly,  raw 
scraped  beef,  custard,  buttermilk,  cheese,  and  ice-cream  should  form  the 
bulk  of  the  diet.  My  plan  is  to  feed  a  portion  of  one  or  two  of  the  above- 
named  foods  every  two  to  three  hours,  thus  giving  ample  nutrition. 

Restoratives. — After  the  spasmodic  stage  subsides  and  the  cough  is 
lessened.  Fowler's  solution  2  to  5  drops  should  be  given  three  times  a  day. 
Codliver  oil  each  teaspoonful  containing  ^/soo  grain  of  phosphorus  should  be 
given  three  times  a  day  after  meals.  If  the  oil  is  well  borne  it  should  be 
continued  throughout  the  winter;  if  not,  give  Fellow's  syrup  of  hypo- 
phosphites. 


CHAPTER  III. 

PNEUMONIA  (LOBAR  OR  CROUPOUS). 

This  acute  infectious  disease  is  frequently  seen  in  infancy  and  cliild- 
hood.  It  is  caused  by  the  invasion  of  a  specific  micro-organism,  the  pneu- 
mococcus;  also  known  as  the  micrococcus  lanceolatus.  The  disease  rarely 
exists  longer  than  from  six  to  nine  days.  It  terminates  by  crisis.  It  is  a 
self-limited  disease.    In  some  cases  it  may  terminate  by  lysis. 

Etiology. — ^This  disease  most  frequently  exists  in  children  between  the 
ages  of  5  and  10  years.  Baginsky  states  that,  among  173  pneumonias 
studied  by  him,  he  found  the  following : — 

6  children  less  than  1  year  old. 
28  children  between  1  and  2  years. 
58  children  between  2  and  5  years. 
63  children  between  5  and  10  years. 
18  children  between  10  and  14  years. 

We  find  on  studying  the  above  cases  that  the  greater  number  of  pneil- 
monias  are  found  in  children  between  the  ages  of  5  and  10  years.  Schles- 
inger  studied  a  series  of  cases  of  pneumonia  and  found  that  96  cases  affected 
the  right  lung  as  against  66  cases  affecting  the  left  lung.  He  also  found  on 
the  right  side  of  the  lung: — 

22  cases  affecting  the  upper  lobe. 

7  cases  affecting  the  middle  lobe. 
32  cases  affecting  the  lower  lobe. 

On  the  left  side  of  the  lung: — 

11  cases  affecting  the  upper  lobe. 
0  cases  affecting  the  middle  lobe. 
47  cases  affecting  the  lower  lobe. 

Thus  he  found  that  the  lower  lobes  on  both  sides  of  the  lungs  were 
more  frequently  affected  than  the  upper  lobes,  and  that  the  seat  of  pneu- 
monia in  children  corresponded  with  the  investigations  of  von  Dusch, 
showing  that  the  most  frequent  seat  of  pneumonia  of  the  lobar  variety  is 
certainly  found  at  the  base  of  the  lower  lobe  of  the  left  lung.  This  is  an 
important  diagnostic  point  when  symptoms  point  to  the  development  of 
pneumonia. 
(460) 


PNEUMONJA. 


461 


Fig.  145. — Focal  Metastatic  Hematogenous  Streptococcus  Pneumonia 
Following  Angina,  (a)  Pneumonic  focus  with  streptococci  (blue)  ;  inflamed 
surrounding  tissue.     X  80.     (Ziegler.) 


Fig.  146. — Croupous  Pneumonia.  Red  hepatization  of  the  lung  (alco- 
hol, carmine,  fibrin-stain),  (a)  Infiltrated  alveolar  septa;  (b)  fibrinous 
exudate;    (c)   red  blood-cells.     X  200.     (Ziegler.) 


463  DISEASES  OF  THE  BRONCHI,  LUNGS,  AND  PLEURA. 

Bacteriology. — ^The  disease  originates  by  an  invasion  of  a  specific  micro- 
organism first  described  by  A.  Fraenkel.  Other  investigators,  among 
them  Klebs,  Ziehl,  and  C.  Friedlander,  have  found  various  micro-organisms 
in  the  lymph  channels,  and  in  the  alveoli  of  pneumonic  lungs.  Some  of 
these  germs  have  been  encapsulated.  It  remained,  however,  for  Fraenkel  to 
find  the  specific  germ  causing  this  disease.  Weichselbaum  was  one  of  the 
first  to  prove  the  positive  specific  infection  of  the  Fraenkel  diplococcus. 
This  diplococcus  is  found  not  only  in  the  lungs,  but  frequently  also  in  the 
meninges,  in  the  nasal  secretions  from  the  nasal  mucous  membrane,  and  at 
times  in  the  kidneys.  Wherever  this  micro-organism  is  found  there  is 
usually  an  inflammatory  condition  resulting  therefrom. 

When  this  speeific  germ  was  injected  into  animals,  pneumonia  always 
resulted. 

Pathology. — The  infection  is  usually  caused  by  the  pneumococcus.  In 
pleuro-pneumonia  both  the  visceral  and  the  parietal  pleura  are  coated  with 
a  large  layer  of  yellowish-green  fibrin,  in  thick,  shaggy  masses,  by  which  the 
lung  is  adherent  to  the  chest-wall,  the  diaphragm,  and  the  pericardium. 
The  exudation  varies  between  one-eighth  and  one-half  inch  in  thickness. 
It  can  often  be  stripped  from  the  lung  or  scraped  from  the  chest-wall  by  the 
handful.  In  its  meshes  small  pockets  may  form,  which  contain  only  a  few 
drops  or  sometimes  a  drachm  of  pus,  or,  less  frequently,  serum.  This  is  the 
condition  in  which  the  lung  is  usually  found  when  death  has  occurred  at  the 
height  of  the  disease.  If  the  process  has  lasted  longer,  larger  collections  of 
pus  may  be  present.  The  lung  itself  shows  the  usual  changes  of  pneumonia, 
and  if  there  has  been  any  considerable  accumulation  of  fluid  there  are  in 
addition  the  evidences  of  compression. 

With  pleuro-pneumonia  of  the  left  side,  the  pericardium  is  occasionally 
involved.  This  was  seen  in  two  of  my  cases,  the  lesions  closely  resembling 
those  of  the  pleura.  In  two  cases  there  was  also  meningitis,  and  in  one 
peritonitis,  the  exudation  in  all  cases  having  the  same  characteristics  (Holt). 

There  are  four  stages  which  have  an  important  bearing  on  the  progress 
and  on  the  outcome  of  this  disease:  first,  the  stage  of  congestion;  second, 
the  stage  of  red  hepatization;  third,  the  stage  of  gray  hepatization,  and, 
fourth,  the  stage  of  defervescence  or  resolution. 

Varieties  op  Pneumonia. 

Abortive  Pneumonia. — This  form  of  pneumonia  is  frequently  disbe- 
lieved by  some  clinical  observers.  At  times  children  who  are  in  apparent 
good  health  will  suddenly  have  intense  fever,  cough,  and  on  physical  ex- 
amination show  distinct  symptoms  of  pneumonia.  Frequently  dullness  on 
percussion  in  addition  to  bronchial  breathing  will  be  plainly  made  out.  In 
two,  possibly  three  days,  the  whole  clinical  picture  will  be  changed  and  the 


WANDERING  PNEUMONIA. 


463 


Fig.  147. — Case  of  Influenza  and  Pneumonia.  The  disease  spread  from 
lobe  to  lobe,  so  that  the  child  passed  through  several  distinct  inflammations. 
This  form  is  known  as  Pneumonia  Migrans  {Wandering  Type).  Careful 
dieting,  aided  by  stimulation,  and  the  fever  treated  by  cold  compresses  and 
cold  colon  flushings  aided  recovery.      (Original.) 


464  THE  INFECTIOUS  DISEASES. 

child  will  appear  to  be  normal.  This  form  of  pneumonia  has  been  recog- 
nized and  studied  by  other  authors,  but  B^aginsky  maintains  that  the  dis- 
ease is  of  the  abortive  type.  It  is  quite  possible  that  some  of  these  symptoms 
have  been  latent  for  several  days  prior  to  the  detection  of  the  physical  signs, 
and  thus  what  appears  to  be  an  abortive  form  of  pneumonia  covering  two 
or  three  days  may  easily  have  existed  for  several  days  prior  to  the  detection 
of  the  same. 

Pneumonia  Gastrica. — This  form  of  the  disease  is  one  in  which  the 
symptoms  of  vomiting  and  diarrhoea  predominate,  and  hence  it  is  known 
as  the  gastric  type  of  pneumonia.  While  the  lungs  will  show  the  usual 
symptoms  of  a  croupous  pneumonia,  the  tongue,  stomach,  and  bowels  will 
present  sj'mptoms  of  an  intense  inflammatory  condition  of  the  digestive 
tract.    Not  infrequently  jaundice  may  be  present. 

The  conjunctival  mucous  membrane  may  be  pigTuented'from  the  pres- 
ence of  bile.  The  secretions  may  also  show  biliary  pigmentation.  Herpes 
may  appear  on  the  upper  lip,  thus  showing  that  there  is  an  intense  inflam- 
matory condition  affecting  primarily  the  digestive  tract. 

Wandering  Pneumonia  ("Pneumonia  Migrans"). — This  form  of  pneu- 
monia is  met  with  quite  frequently.  The  symptoms  are  those  common  to 
lobar  pneumonia,  as  chills,  fever,  and  the  usual  physical  symptoms  of  a 
consolidated  lung  in  this  condition.  The  name  is  derived  from  its  tendency 
to  spread  from  lobe  to  lobe.  The  infection  usually  commences  in  one  lobe 
and  spreads  to  the  second,  ■  to  the  third,  and  frequently  when  the  crisis 
has  taken  place  the  disease  commences  with  full  force  in  another  lobe  and 
may  continue  so  for  several  weeks.  That  this  form  of  pneumonia  is  very 
serious  can  be  easily  imagined.  A  child,  having  suffered  with  acute  lobar 
pneumonia  and  passed  its  crisis  with  an  already  weakened  heart,  has 
again  to  pass  through  the  second  pneumonia  and  frequently  through  a  third 
and  a  fourth,  and  must  certainly  have  great  vitality  in  order  to  recover  from 
the  depression  caused  thereby. 

Pleuro-pneumonia. — It  is  rare  to  find  lobar  pneumonia  without  an  as- 
sociated inflammation  of  the  pulmonary  pleura.  Not  infrequently  with  a 
severe  type  of  broncho-pneumonia  covering  large  areas  of  consolidation  there 
is  a  coexisting  inflammation  of  the  pleura.  It  is  difficult  to  state  at  times 
which  lesion  began  first,  whether  it  was  the  pleurisy  or  the  pneumonia,  in  a 
given  case  of  pleuro-pneumonia. 

Cerebral  Pneumonia, — This  type  of  the  disease  is  one  which  is  very 
frequently  met  with  in  which  the  symptoms  of  pneumonia  are  chiefly  com- 
plicated by  meningeal  symptoms;  thus  clonic  spasms  or  convulsions  are 
usually  present.  In  addition  thereto  there  is  vomiting,  constipation,  head- 
ache, opisthotonos,  delirium,  stupor,  irregularity  of  the  pulse,  and,  later 
on  in  the  disease,  coma.    In  some  cases  paralysis  is  liable  to  occur. 


CEREBRAL  PNEUMONIA.  465 

.  Symptoms  and  Course. — The  disease  is  usually  ushered  in  with  con- 
vulsions. At  times  vomiting  and  diarrhoea  may  be  the  first  symptoms 
noticed.  Chills  are  very  rarely  seen  in  children.  The  cheeks  are  usually 
very  red  and  show  the  characteristic  flush  so  well  known  in  adult  pneu- 
monia. The  respirations  are  increased,  the  pulse  is  accelerated,  and  the 
temperature  rises.  One  of  the  most  important  diagnostic  points  and  one 
upon  which  I  lay  great  stress  is  the  "ratio  hetkveen  the  pulse  and  respira- 
tion/' Normally  the  ratio  is  1  to  4,  and  when  this  ratio  is  increased,  as, 
for  example,  when  there  are  60  respirations  and  140  pulse  beats,  then  the 
ratio  of  1  to  4,  which  normally  existed,  is  certainly  disturbed.  By  this 
disturbed  ratio  alone  we  can  frequently  make  a  diagnosis  by  the  process  of 
exclusion.  Especially  is  this  true  in  those  cases  of  "central  pneumonia"  in 
which  the  disease  develops  in  the  center  of  the  lung  and  gradually  spreads 
toward  the  periphery.  When  such  central  pneumonia  exists,  the  physical 
signs  will  be  so  masked  that  bronchial  breathing  will  be  hardly  discern- 
ible. The  temperature  will  suddenly  rise  to  103°,  103°,  and  frequently 
to  105°  F.  The  temperature  in  rachitic  children  will  sometimes  rise 
to  106°  and  107°  F.  It  is  this  class  of  cases  that  shows  the  most  severe 
form  of  depression  from  irritation  of  the  thermic  centers.  In  these  rachitic 
children  we  usually  note  that  the  invasion  of  pneumonia  begins  with  a  con- 
vulsion or  a  series. of  convulsions. 

Children  old  enough  will  frequently  complain  of  abdominal  pains. 
Thus  we  must  not  be  misled  by  gastric  or  gastro-intestinal  s}Tnptoms  until 
we  can  exclude  the  lungs  as  the  seat  of  the  disease.  The  physical  sign  most 
commonly  associated  with  this  disease  is  dullness  on  percussion  over  the 
affected  area  of  the  lung.  In  addition  thereto  there  will  be  bronchial  breath- 
ing. If  the  child  cries,  a  loud  bronchophony  will  be  heard.  There  will  also 
be  an  increased  vocal  fremitus.  These  sjonptoms  usually  remain  the  same 
for  a  few  days,  although  they  may  increase  in  intensity. 

Between  the  sixth  and  the  ninth  day,  rarely  earlier  and  very  rarely 
later,  a  crisis  takes  place,  in  which  the  temperature  will  suddenly  drop  to 
normal.  The  patient  will  be  covered  with  a  profuse  perspiration ;  the 
pulse,  which  formerly  was  full,  bounding  and  accelerated,  will  be  found 
smaller  and  less  frequent.  The  former  flush  which  existed  will  give  place 
to  a  distinct  pallor  of  the  skin,  and  the  observing  physician  will  note  a 
decided  change  in  the  patient.  This  condition,  known  as  the  crisis,  may 
come  on  suddenly  or  gradually.  In  some  cases  the  fever  drops  slowly — 
i.e.,  by  lysis — until  normal  is  reached. 

Pulse. — The  pulse-rate  is  one  which  is  a  very  important  factor  in  con- 
nection with  this  disease.  While  it  may  be  120  and  be  quite  regular  in 
action,  it  is  not  uncommon  to  find  the  pulse-rate  140,  and  even  160.  The 
frequency  of  the  pulse  is  not  as  important  a  factor  in  determining  the 
progress  of  this  disease  as  is  the  character  of  the  pulse.     Thus,  to  illus- 

so 


466  THE  INFECTIOUS  DISEASES. 

trate,  if  a  pulse  is  not  frequent,  but  is  weak  and  arrhythmic,  such  a  patient 
should  be  regarded  as  in  imminent  danger  and  requiring  very  frequent  and 
careful  stimulation.  A  condition  of  collapse  may  be  looked  for  in  such  a 
patient,  and  treatment  directed  to  the  prevention  of  the  same  is  indicated. 
If  the  pulse-rate  has  been  120,  and  it  suddenly  increases  to  140  or  more, 
then  some  complication  must  be  suspected  and  the  child  carefully  exam- 
ined to  determine  the  cause  of  this  sudden  increase  of  the  pulse-rate. 

Respiration. — The  whole  respiratory  condition  is  superficial  and  seems 
to  call  the  accessory  respiratory  muscles  into  play.  When  the  respiration 
is  above  40  per  minute,  the  diagnosis  is  usually  very  positive. 

Lach  of  Expansion. — A  lack  of  expansion  may  also  be  noticed.  It 
involves  the  whole  of  the  affected  side  and  is  not  limited  to  the  sub- 
clavicular region.  In  pneumonia  this  lack  of  expansion  in  the  subclavicular 
region  is  marked,  even  though  the  inflammatory  process  is  situated  at  the 
base.  It  can  be  observed  as  early  as  the  first  day,  and  lasts  throughout  the 
entire  course  of  the  disease.  This  early  appearance  of  the  sign  is  of  especial 
importance,  since  the  physical  signs  of  involvement  of  the  lung  are  so 
frequently  delayed  in  cases  of  infantile  pneumonia. 

The  sign  is  best  elicited  in  the  dorsal  position,  and  is  easily  seen  on  the 
exposed  chest  in  quick  respiration. 

One  writer  says  he  has  recognized  by  this  sign  alone  pneumonia  occur- 
ring in  a  supposed  case  of  appendicitis,  and  also  has  discovered  pneumonia 
complicating  typhoid  and  influenza. 

The  Temperature. — A  rise  of  temperature  usually  implies  the  invasion 
of  the  specific  micro-organism  and  hence  is  one  of  the  earliest  symptoms 
of  this  disease.  It  usually  rises  from  102°  to  105°  F.,  and  remains  so  until 
the  crisis.  There  is,  however,  a  morning  remission;  thus  we  find  the  tem- 
perature about  one  degree  lower  in  the  morning  than  we  do  in  the  evening. 
In  pneumonia  we  frequently  find  a  condition  known  as  the  "procrisis.'^  This 
procritical  stage  exists  one  day  before  the  crisis,  as  a  rule.  The  temperature 
will  suddenly  fall  to  normal  on  the  day  preceding  the  crisis.  It  has  a  valu- 
able prognostic  significance,  showing  that  the  inflammatory  stage  has  now 
terminated. 

In  Pleuro-pneumonia. — Symptoms:  The  friction  sound  is  the  charac- 
teristic feature  throughout.  In  addition  to  the  pleuritic  friction  sounds, 
the  symptoms  of  pneumonia,  such  as  bronchial  breathing  and  bronchophony, 
are  found.  There  is  marked  dullness  and  frequently  flatness  on  percussion. 
This  condition  is  sometimes  misleading.  Not  infrequently  the  signs  of  dis- 
tant breathing  and  flatness  on  percussion,  in  addition  to  a  continuous  high 
temperature,  will  simulate  an  empyema.  An  exploratory  needle  introduced 
may  strike  a  small  pocket  of  pus  and  thus  an  empyema  may  be  suspected. 
These  cases,  if  operated,  frequently  show  nothing  but  the  ordinary  signs  of 
adhesions  so  common  at  this  stage  of  the  disease. 


CEREBRAL  PNEUMONIA. 


467 


The  Blood  in  Pneumonia. 
— Baginsky  maintains  that  the 
examination  of  tlie  blood  will 
show  the  progress  of  this  dis- 
ease, and  he  believes  that  the 
leucoeytosis  so  common  in  this 
disease  has  an  important  bear- 
ing on  the  prognosis  of  this 
condition.  Felsenthal  and 
Schlesinger,  also  Monti,  Berg- 
griin,  and  Loos,  have  found 
that  there  is  an  increase  of  the 
polynuclear  cells,  whereas  the 
eosinophile  cells  disappear. 
When  the  temperature  returns 
to  normal  during  the  crisis  in 
pneumonia,  the  leucoeytosis 
which  formerly  existed  also 
disappears.  Thus,  some  au- 
thors speak  of  a  "TDlood  crisis." 

The  Urine. — This  is  fre- 
quently high-colored  and  very 
scanty,  especially  so  during  the 
height  of  the  disease.  It  also 
has  a  very  high  specific  gravity 
and  frequently  contains  albu- 
min. Acetone  can  also  fre- 
quently be  found  in  the  urine. 
The  albumin  frequently  dis- 
appears after  the  crisis.  The 
phosphates  seem  increased, 
though  some  authors  maintain 
that  they  are  decreased  during 
the  progress  of  this  inflamma- 
tory type  of  disease.  The 
diazo  reaction  is  only  found  in 
that  form  of  pneumonia  which 
seems  to  have  a  typhoid  tend- 
ency. Indican  is  very  rarely 
or  never  found  unless  there  is 
some  form  of  intestinal  putre- 
factive complication. 


Fig.  14S. — Lobar  Pneumonia  of  a  Severe 
Type,  seen  by  me  in  consultation  with  Dr.  S. 
M.  Landsmann.  The  effect  of  the  poison  is 
easily  seen  by  studying  the  pulse-rate.  Case 
Recovered.     (Original.) 


468 


THE  INFECTIOUS  DISEASES. 


Relapse. — It  is  not  infrequent  to  have  one  and  the  same  area  of  lung 
reinvaded ;  thus  the  disease  may  run  a  second  course  over  the  same  portion 
of  the  lung  just  as  it  did  in  the  first  attack. 

Two  Insteuctive  Cases  of  Cebebbai,  Pneumonia. 

Case  I. — Baby  E.,  about  six  months  old,  a  nursing  baby,  was  seen  by  me  in 
consultation  with  Dr.  Osias.  The  history  was  as  follows:  The  child  had  been  ill  for 
several  days,  was  restless  and  feverish,  and  had  vomited.  The  stools  were  green- 
ish and  contained  a  large  quantity  of  cheesy  curds,   in  addition  to  mucus.     The 


Fig.    149. — ^A  Case  of  Cerebral  Pneumonia.     (Original.) 


abdomen  was  slightly  retracted,  the  extremities  were  cold;  there  was  no  oedema 
present.  The  child  did  not  seem  to  take  the  breast  very  well  and  vomited  fre- 
quently after  nursing.  The  temperature  was  102Vb°  F.,  per  rectum,  pulse  140, 
respiration  44.  Unilateral  spasms  with  twitchings  of  the  muscles  of  the  shoulder, 
arm,  leg,  and  foot  were  constantly  present.  Twitchings  of  the  muscles  of  the 
eye  and  a  constant  rolling  of  the  eyeball  were  noticed;  the  head  was  thrown 
backward;  the  muscles  of  the  neck  were  rather  rigid,  although  there  was  no  distinct 
opisthotonos.  The  spasms  were  confined  to  the  right  side  of  the  body;  the  knee- 
jerk  at  the  patella  was  absent  on  the  right  side;  the  plantar  reflex  on  the  right  side 
was  slightly  present;  the  patellar  reflex  was  normal  on  the  left  side  and  the  plantar 
reflex  was  more  distinct;  the  pupils  responded  very  sluggishly  and  were  unusually 
large;  this  dilatation  of  the  pupils  persisted  through  the  whole  illness,  until  con- 


CEREBRAL  PNEUMONIA. 


4G9 


valescence  was  established.  The  examination  of  the  thorax  showed  intense  pul- 
monary congestion;  there  was  slight  resistance  on  percussion  and  marked  dullness. 
Judging  from  the  ratio  between  the  pulse  and  the  respiration,  the  diagnosis  of 
pneumonia  was  hardly  possible.  The  physical  signs  on  auscultation  showed  bronchial 
breathing  and  a  distinct  crepitant  rale.  The  diagnosis  of  cerebral  pneumonia  was 
made,  although  meningitis  per  se  was  excluded. 

The  treatment  was  directed  to  relieve  the  pneumonic  infection.  Expectorants, 
in  addition  to  inhalations  of  steam,  were  ordered.  Cold  compresses  were  used 
as  antipyretics,  and  castor-oil  or  calomel  was  given  to  cleanse  the  gastro-intestinal 
tract.     The  disease  progressed;   the  temperature  increased  and  rose  to   103Vb°   F. 


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Fig.    150. — Cerebral  Pneumonia  with  High  Temperature  and  Marked 
Decrease  in  Temperature  After  Cold  Baths.      (Original.) 


on  the  following  day,  and  to  10476°  F.  on  the  third  and  fourth  days.  With  the 
rise  of  temperature  the  pulse-rate  was  increased  to  140,  respirations  to  52.  On 
the  fifth  day  of  the  disease  there  was  a  marked  somnolence,  stupor  and  partial 
coma.  The  head  now  showed  a  distinct  opisthotonos;  the  sterno-cleido-mastoids 
were  very  rigid;  the  pupils  were  both  dilated  and  the  convulsions  continued  as 
before.  Leeches  were  applied  over  the  mastoid  portion  of  the  temporal  bone  to 
relieve  the  cerebral  congestion;  the  scalp  was  shaved  and  iodoform  collodion, 
10  per  cent.,  was  painted  on  the  occiput;  ice-bags  were  applied  over  the  whole  of 
the  cranium  as  well  as  to  the  nape  of  the  neck;  mustard  foot-baths  were  frequently 
given  and  afforded  some  relief  during  the  severe  spasms.  An  enema  consisting  of 
chloral  hydrate  and  sodium  bromide,  5  grains  each,  with  1  ounce  of  starch  water, 
was  ordered.  This  was  to  be  repeated  every  three  hours  until  the  spasms  ceased. 
Before  injecting  the  above  drugs  both  the  rectum  and  the  colon  were  flushed  with 
soap-water  enema. 

On  the  seventh  day  of  the  disease  there  was  a  distinct  crisis,  inasmuch  as  the 


470  THE  INFECTIOUS  DISEASES. 

temperature  dropped  from  104°  to  97°,  a  drop  of  7  degrees.     (Fig.  154.)     Stimula- 
ting expectorants  were  then  ordered  in  the  following  manner: — 

IJ  Ammon.  carb 15  grains 

Syrup,   pruni  virgin    4  drachms 

Aquse  camph q.  s.  ad  2  ounces 

M.    Half  a  teaspoonful  every  two  hours. 

The  child's  convalescence  continued.  The  pneumonia  completely  subsided;  reso- 
lution set  in ;  the  spasms,  which  had  been  so  disagreeable  and  persistent,  also  stopped. 
The  child  commenced  to  show  signs  of  consciousness,  played,  laughed,  and  cooed;  the 
stools,  which  had  been  so  greenish  and  curdled,  assumed  a  more  natural  yellowish 
color  and  pasty  consistency.  The  appetite  seemed  to  return;  the  infant  nursed 
better,  the  nights  were  more  comfortable,  and  the  child  slept  from  one  feeding  time 
until  the  next. 

Case  II. — Hannah  T.,  7  years  old,  was  taken  sick  with  fever,  complained  of 
being  tired,  and  was  very  thirsty.  She  had  anorexia  and  was  inclined  to  constipation. 
She  also  complained  of  headaches.  When  first  seen  by  me  her  temperature  was 
103.4°  F.  in  the  mouth,  the  pulse  168,  respiration  34.  She  had  a  very  coated  tongue; 
the  throat  was  dry;  there  were  no  patches  visible.  There  was  no  history  of  exposure 
to  contagious  diseases;  a  gastric  catarrh  was  suspected.  The  respiration  and  pulse 
ratio  suggested  a  pulmonary  complication. 

The  physical  examination  of  the  thorax  gave  no  evidence  of  consolidation, 
merely  roughened,  harsh  breathing,  some  rhonchi  and  slight  resistance  on  percussing 
the  right  apex  anteriorly.  No  diagnosis  except  "fever"  was  made.  I  ordered 
calomel  1  grain  with  powdered  rhubarb  3  grains.  Citrate  of  magnesia  was  given 
for  the  thirst.  A  fluid  diet,  consisting  of  equal  parts  of  Seltzer  and  milk,  with 
sponging  of  the  chest  with  alcohol  and  water  every  hour,  and  cool  cloths,  moistened 
with  evaporating  lotions  like  bay  rum  or  Florida  water,  to  the  forehead  were  also 
ordered. 

I  examined  a  specimen  of  urine  which  contained  nothing  abnormal.  On  the 
following  morning,  twelve  hours  after  my  first  visit,  the  temperature  by  rectum 
was  104.4°  F.,  pulse  172,  respiration  68  while  asleep.  The  bowels  had  been 
thoroughly  cleaned,  still  there  was  no  evidence  of  pneumonia,  but  the  child  seemed 
to  be  greatly  depressed.  There  was  marked  apathy;  the  child  was  very  restless  and 
had  not  slept.  Constant  twitchings  of  the  muscles  of  the  face  and  extremities 
occurred;  the  child  cried  out  while  in  the  stupor,  refused  food,  attempted  to  bite 
and  screamed  loudly.  The  patellar  reflexes  were  both  present,  the  pupils  reacted 
normally,  the  head  was  not  retracted  nor  were  the  muscles  rigid.  There  was  no 
jpisthotonos;  the  child  could  be  roused  by  loud  talking,  or  by  being  touched. 
The  temperature  in  the  evening  was  106.2°  F.  by  rectum,  the  pulse  124,  respiration 
40.  One-drop  doses  of  tincture  of  aconite  were  given  every  hour  for  eight  hours 
ftnd  had  no  effect  on  the  temperature,  but  did  seem  to  reduce  the  pulse-rate  attd 
steady  the  heart's  action. 

The  cold  pack  was  ordered,  to  be  renewed  every  half-hour  until  the  temperature 
dropped  to  102°  F.  Freshly  prepared  spiritus  mindererus,  one-half  teaspoonful  every 
half-hour  until  the  temperature  remained  at  102°  F.,  was  also  ordered.  Warm 
mustard  foot-baths  were  ordered  to  stimulate  the  circulation,  and  whisky  with  milk 
(3j  to  5iv),  whenever  possible.  No  distinct  evidences  of  pneumonia  were  obtained  on 
auscultation  or  percussion. 

The  temperature  continued  to  rise,  until  106°  F,  was  reached.  Dry  cups  were 
applied  over  the  posterior  portion  of  the  lungs;  also  an  ice-cap  to  the  head.     Colon 


CEREBRAL  PNEUMONIA.  47 1 

flushings  with  water  at  a  temperature  of  60°  F.  Avere  also  ordered,  to  be 
repeated  every  three  hours.  These  seemed  to  have  a  very  soothing  effect  on  the 
nervous  system.  The  child  was  much  quieter  after  them  and  tlie  temperature  was 
gradually  reduced. 

Frequently  after  a  cool  tub  bath,  combined  with  a  cold  pack,  the  temperature 
dropped  three  to  four  degiees.  (Fig.  150.)  Creosote  carbonate,  in  3-drop  doses, 
was  ordered  every  three  hours,  to  be  given  in  milk,  soup  or  chocolate.  This  dose 
was  increased  gradually  by  the  addition  of  one  drop  each  day,  until  the  child 
received  ten  drops  every  four  hours.  No  systemic  disturbance  was  noticed,  there 
was  no  discoloration  of  the  urine  and  no  toxic  symptoms  resulted  from  the  creosote 
treatment.  A  decided  antithermic  effect  without  cardiac  depression  was  noticed. 
(A  convenient  way  of  giving  the  creosote  is  to  add  the  drops  to- some  Tokay  wine 
or  to  combine  it  with  whisky  and  water.)  The  mustard  foot-baths  given  daily 
acted  as  a  valuable  antipyretic. 

Creosote  steam  inhalations  were  also  ordered.  Beechwood  creosote,  about  a 
teaspoonful  to  a  pint  of  boiling  water,  was  permitted  to  steam  on  a  table  several 
feet  from  the  patient.  This  powerful  vapor  soon  impregnated  the  air,  so  that  the 
creosote  could  be  smelt  throughout  the  whole  apartment.  It  certainly  acted  very 
well,  not  only  on  the  temperature,  but  also  in  loosening  viscid  secretion. 

The  vital  point  in  the  treatment  consisted  in  giving  a  supporting  diet  of  eggs 
beaten  up  with  sugar  and  Tokay  wine,  concentrated  soups,  and  milk  predigested  with 
peptonizing  powder.  Malt  extract  was  given  as  a  restorative  and  also  for  its 
diastasic  effect.  The  treatment  was  continued  until  the  child's  temperature  remained 
normal  for  several  days,  when  all  forms  of  creosote  were  discontinued. 

It  is  interesting  to  note  that  very  great  depression  of  the  nervous  system, 
violent  twitchings  of  the  muscles,  and  talking  aloud  while  asleep  continued  for 
several  weeks  after  convalescence  was  established.  The  child  slept  at  least  twenty 
hours  out  of  the  twenty-four  for  fully  one  week.  It  was  at  times  difficult  to  arouse 
her  to  take  nourishment.  This  great  stupor  was  evidently  due  to  the  profound 
toxaemia  which  existed.  The  urine,  which  was  frequently  examined,  showed  an 
excess  of  phosphates,  gave  a  strong  diazo  reaction,  contained  neither  albumin  nor 
sugar.    The  child  was  discharged  after  eight  weeks  and  is  in  good  health  to-day. 

The  following  symptoms  were  the  most  noteworthy  in  the  cases  reported: — 

(a)  Unilateral  spasms,  twitchings  of  the  muscles  of  the  shoulder  and  the 
arm,  and  of  the  leg  and  foot,  were  constantly  present.  (6)  Twitchings  of  the 
muscles  of  the  eye  and  a  constant  rolling  of  the  eyeball,  (c)  The  head  was  thrown 
backward.  (d)  The  patellar  reflex  was  absent  on  the  affected  side.  (e)  The 
plantar  reflex  was  slight  on  the  affected  side.  (/)  Distinct  evidences  of  pneumonia, 
bronchial  breathing  and  marked  dullness  on  percussion.  (g)  Convulsions  and 
marked  stupor  later  in  the  disease.  (/;-)  When  the  crisis  appeared  in  the  pneumonia, 
the  cerebral  symptoms  subsided.  (t)  Marked  nervous  depression  and  extreme 
hypersesthesia  of  the  body,  which  continued  for  weeks  after  all  inflammatory  symp- 
toms had  subsided. 

Schlesinger,  in  stiid}dng  this  disease,  noted  that  it  existed  chiefly  in 
children  between  the  third  and  sixth  years. 

In  acute  apical  pneumonia  we  usually  note  cerebral  S}Tnptoms  due  to 
the  irritation  of  the  cervical  ganglion.  These  symptoms  subside  with  the 
crisis  of  pneumonia.  They  must  not  be  confounded  with  meningitis,  which 
is  a  distinct  disease,  although  a  frequent  complication  of  pneumonia. 


4:72  THE  INFECTIOUS  DISEASES. 

Diagnosis. — The  diagnosis  of  pneumonia  is  easy  when  the  physical 
symptoms  of  dullness  on  percussion,  bronchial  breathing,  moist  rales,  and 
bronchophony  are  shown.  These  symptoms  are  not  always  present  and  are 
frequently  absent  during  the  first  few  days  of  the  disease.  The  diagnosis 
can  be  made  by  the  disturbed  ratio  between  pulse  and  respiration,  as  pre- 
viously noted.  In  addition  thereto,  the  peculiar  character  of  the  respira- 
tion, added  to  the  cough,  will  certainly  aid  in  establishing  the  diagnosis. 
The  vital  point  to  remember  is  that,  normally,  bronchial  breathing  is  heard 
posteriorly  between  the  scapulge  and  also  in  the  regio  supraspinata  dextra. 
We  must  also  remember  that  dullness  on  percussion  appears  somewhat 
higher  on  the  right  side  posteriorly  in  the  lower  lobe  than  on  the  left  side. 
The  positive  diagnosis  can  therefore  only  be  made  by  noting  the  physical 
signs  in  the  lungs  and  excluding  the  symptoms  pointing  to  a  gastric  catarrh, 
to  a  typhoid  fever  or  a  meningitis. 

Atalectasis  pulmonum  can  easily  be  differentiated  from  pneumonia  by 
the  absence  of  fever  and  by  the  marked  difference  in  the  dullness  on  per- 
cussion and  usually  by  the  absence  of  bronchial  breathing.  When  fever 
recurs  after  it  has  apparently  terminated,  some  complication  must  be  sus- 
pected. Symptoms  pointing  to  a  pleuritic  effusion  are  dullness  on  percus- 
sion and  diminished  respiratory  murmur  over  the  affected  area.  Gangrene 
of  the  lungs  can  usually  be  detected  by  the  odor  of  the  breath  and  the  asso- 
ciated condition  of  collapse.  If  the  condition  assumes  a  chronic  type  and 
is  associated  with  headache  and  fever,  and  if  the  child,  in  addition,  com- 
mences to  emaciate,  then  we  may  suspect  the  development  of  tuberculosis. 
To  render  such  diagnosis  positive,  some  of  the  sputum  or  expectoration 
should  be  examined  for  the  presence  of  tubercle  bacilli,  the  presence  of 
which  will  establish  the  diagnosis.  The  absence  of  tubercle  bacilli  in  the 
sputum  does  not  necessarily  mean  that  tuberculosis  is  absent. 

The  Prognosis. — The  prognosis  of  croupous  pneumonia  is  ^relatively 
good.  Out  of  173  cases  reported  by  Baginsky,  of  Berlin,  4  per  cent.  died. 
These  latter  children  were  very  poorly  nourished. 

Fatal  cases  may  be  expected  in  bottle-fed  infants  rather  than  in  breast- 
fed infants.  An  abnormal  developed  thorax,  so  common  in  rickets,  has  an 
important  bearing  on  the  prognosis  of  this  disease.  Pigeon-breasted  and 
narrow-chested  infants,  having  an  improperly  developed  lung  space,  are  more 
prone  to  a  fatal  termination. 

The  development  of  symptoms  of  tuberculosis  or  abscess  of  the  lung, 
or  the  extension  of  a  pneumonia  and  the  continuation  of  the  same,  will  mean 
a  depression  of  the  heart's  action  and  an  inhibiting  of  the  recuperative 
tendency.  The  vital  point  will  be  the  question  of  nutrition.  The  greater 
the  amount  of  food  taken  the  better  will  be  the  chance  for  the  patient's 
recovery;  thus  the  maxim  in  treating  a  pneumonia,  "Feed  the  stomach," 
is  one  that  I  have  learned  to  indorse  and  verify. 


LOBAR  PNEUMONIA.  473 

Treatment.^ — The  most  important  symptoms  to  be  remembered  in  the 
treatment  of  this  disease  are  the  condition  of  the  heart,  the  pulse-rate,  the 
respirations,  the  temperature,  and  the  condition  of  the  kidneys,  to  be  noted 
by  the  quantity  and  the  quality  of  the  urine  secreted. 

Isolate  the  Child. — As  lobar  pneumonia  is  an  acute  infectious  disease 
caused  by  the  invasion  of  the  pneumococcus,  it  is  transmissible.  Our  first 
duty  is  to  isolate.  A  case  of  pneumonia  should  be  isolated  as  strictly  as  a 
case  of  diphtheria.  All  healthy  persons  should  be  excluded,  be  they  friends 
or  family.    It  is  best  to  let  them  know  that  this  disease  can  be  disseminated. 

In  the  treatment  of  pneumonia  we  must  remember  that  toxaemia  and 
high  temperature  will  produce  degeneration  of  the  muscular  fiber  of  the 
heart,  which,  if  prolonged,  will  result  in  heart-failure.  Hence  our  treat- 
ment must  be  directed  to  lowering  the  temperature  and  to  control  the 
inflammatory  process  before  stagnation  of  the  blood  and  hepatization  have 
taken  place,  thus  aiming  to  retain  the  integrity  of  the  respiratory  tract. 

Any  interference  with  the  proper  action  of  the  respiratory  apparatus 
leads  to  overloading  and  ultimate  failure  of  the  right  side  of  the  heart. 
Hence  we  must  seek  to  keep  up  the  respiratory  pump  by  lessening  the  fre- 
quency and  increasing  the  depth  of  the  respirations. 

A  great  many  cases  will  get  well  without  treatment.  This  is  called  the 
"self-limited"  condition.  The  disease  simply  runs  its  course,  and  if  the 
patient  is  properly  fed,  strengthened,  and  guarded,  a  favorable  termination 
may  be  expected.  On  the  other  hand,  there  are  certain  symptoms  which 
demand  treatment.  For  example,  hyperpyrexia  will  require  treatment,  espe- 
cially so  as  the  continuation  of  the  same  may  be  the  means  of  developing 
disturbances  resulting  in  convulsions.  My  preference  has  always  been  for 
the  use  of  cold  externally.  If  cyanosis  exists  then  warm  flaxseed  poultices 
may  be  tried. 

The  sudden  application  of  cold  externally  causes  a  deep  inspiration  and 
consequent  forcing  of  air  through  the  alveoli,  thus  preventing  atelectasis. 
The  air  surrounding  the  child  should  be  kept  moist  with  steam  from  a  tea- 
kettle having  a  long  spout  directed  toward  the  child  (Fig.  134). 

The  following  case  was  attended  by  me  in  the  babies'  ward  of  the  New 
York  Post-Graduate  Hospital: — 

Child  F.  A.,  5  years  old.  My  attention  was  called  on  August  12th  to  a  tem- 
perature of  99Vb°  F.,  which  rose  to  10475°  F.,  by  8.30  the  following  evening.  Per- 
cussion showed  dullness  over  a  complete  lobe  of  the  left  lung,  bronchial  breathing, 
cough,  no  expectoration.  The  respiration  rose  from  36  in  the  morning  to  50 
in  the  evening,  and  the  pulse  from  120  to  130  per  minute.  Until  the  diagnosis 
was  positive  the  child  was  put  on  the  expectant  plan  of  treatment.  The 
temperature  rose  to  105°  F.  on  the  second  day,  in  spite  of  sponge  baths  con- 
sisting of  equal  parts  of  alcohol  and  water.  After  a  few  hours  the  temperature 
rose  to  its  former  height,  sometimes  going  beyond  that,  prior  to  the  sponge  bath. 


^  For  vaccine  treatment,  see  "Bacterial  Vaccines. 


474  THE  INFECTIOUS  DISEASES, 

In  order  then  to  have  a  more  lasting  efiFect,  it  was  deemed  necessary  to  give 
the  tub  bathSj  that  is,  to  immerse  the  child  from  the  neck  to  the  feet  in  water  of 
about  90°  F.  and  then  add  ice  until  the  temperature  of  the  bath  is  70°  F.  The 
child  was  kept  in  the  bath  from  two  to  five  minutes. 

The  first  tub  bath  brought  the  temperature  from  104V6°  F.  to  100°  F.  This 
drop  lasted  about  two  hours.  The  temperature  did  not  rise  more  than  two  degrees 
until  the  following  afternoon  at  4  p.m.,  when  it  reached  104V6°  F.  This  is  a  natural 
course  in  a  severe  pneumonia.  The  second  tub  bath  had  the  effect  of  lowering  the 
temperature  from  104Vs°  F.  to  101Vb°  F.,  a  decrease  of  SVj"  F.  in  one  hour. 

On  the  19th  of  August,  the  eighth  day  of  the  disease,  the  temperature  reached 
10476°  F.  at  6  P.M.  A  tub  bath  given  brought  the  temperature  to  103°  F.  at  7  P.M., 
a  fall  of  1Vb°  E.  in  one  hour.  This  same  temperature  continued  until  9  p.m.,  after 
which  it  began  to  fall,  reaching  normal  on  the  following  day,  the  ninth  day  of 
disease.  The  boy  was  discharged  cured.  He  was  entirely  well  when  I  last  heard  of 
him. 

In  the  above  case  true  symptomatic  treatment  was  carried  out.  The  severe 
cough  received  an  expectorant  with  an  anodyne  (codeine)  when  necessary  to  relieve 
pain.  Bowels  and  bladder  were  carefully  watched.  Stimulants  given  when  required 
— no  antipyretics.  Diluted  milk  and  whey,  every  three  hours.  Cool  water  when- 
ever thirsty. 

Drug  Treatment. — When  high  fever  persists  in  a  weakened  child  with 
very  low  resisting  power,  such  fever  must  be  reduced.  The  child's  system 
must  be  carefully  watched  while  fever  is  in  progress.  One  child  will  tol- 
erate a  temperature  of  105°  F.,  laugh  and  play,  and  take  its  food  regularly, 
while  another  child  in  a  similar  pulmonary  condition  will  show  extensive 
cerebral  irritation,  somnolence,  tremor,  twitching  of  the  muscles,  and  pos- 
sibly convulsions  at  a  temperature  of  103°  or  104*  F.  In  the  latter  instance 
it  shows  that  the  poison  from  the  pneumococcus  infection  has  overwhelmed 
the  nerve  centers  governing  heat  production,  and  in  such  instances,  when 
decided  nervous  or  cerebral  symptoms  present  themselves,  "a  reduction  of 
temperature  is  demanded,"  or  we  must  not  be  surprised  to  see  convulsions 
set  in,  with  probably  a  fatal  termination. 

How  Shall  We  Reduce  the  Temperature  in  Children? — When  we  con- 
sider that  antipyretic  drugs  depress  the  nerve  centers  governing  heat  pro- 
duction and  increase  the  work  of  the  emunctories,  already  loaded  down  by 
poison  brought  to  them  for  elimination,  it  can  be  seen  that  their  use  is 
contraindicated.  Those  who  believe  in  phagocytosis  may  be  reminded  that 
antipyretics  arrest  the  development  of  leucocytosis,  and  thus  remove  one  of 
the  means  of  destroying  the  germs  of  the  disease,  according  to  one  theory, 
or  the  antitoxin  generated  or  developed,  according  to  another  (Hobart  A. 
Hare) . 

Jacubowitsch  and  Muller  and  many  others  have  proved  conclusively 
that  antipyrine  decreases  the  elimination  of  urea  by  the  urine.  It  also 
decreases  the  urinary  flow,  which  is  a  very  harmful  effect,  when  we  con- 
eider  the  great  importance  of  eliminating  effete  matter  from  the  body. 


LOBAR  PNEUMONIA.  475 

That  antipyretics  depress  the  heart's  action  is  only  too  well  known;  there- 
fore, rather  than  to  combine  them  with  musk,  camphor,  or  other  cardiac 
stimulants,  I  have  discarded  them. 

Lactophenin,  antipyrine,  phenacetin,  salol,  salipyrine,  and  quinine  are 
among  the  more  common  antipyretic  measures  used  as  indicated,  but,  as  they 
are  cardiac  depressants,  must  be  cautiously  prescribed.  The  tincture  of 
aconite,  in  1-minim  doses,  repeated  every  hour,  has  a  remarkably  good  effect 
on  this  disease.  In  addition  thereto,  spirits  of  mindererus  in  half-teaspoonful 
doses,  repeated  every  hour,  will  have  a  very  good  diaphoretic  effect.  Dover's 
powder  will  relieve  cough  and  will  also  aid  diaphoresis. 

For  difficult  breathing  nothing  will  serve  as  well  as  local  depletion. 
For  this  purpose  the  application  of  dry  cups  over  the  affected  areas  of  the 
lung  will  afford  in  some  instances  immediate  relief.  Dry  cupping  may 
be  repeated  every  hour  in  severe  dyspnoea  if  necessary.  Tincture  of  iodine 
applied  locally  over  the  area  of  the  lung  affected  will  also  be  advantageous 
in  some  instances.  If  the  pain  is  severe  in  pleuro-pneumonia,  strapping  the 
chest  with  strips  of  adhesive  plaster  will  support  the  ribs  and  relieve  the 
cough. 

If  convulsions  persist  an  ice-bag  applied  over  the  head  and  also  at  the 
nape  of  the  neck  will  be  very  valuable. 

I  frequently  use  one  or  two  leeches  applied  over  the  mastoid  process 
'of  the  temporal  bone  and  permit  very  free  bleeding.  This  is  especially 
indicated  when  there  is  intense  engorgement  of  the  brain  with  marked 
stupor  and  coma.  We  can  frequently  relieve  conigestion  by  the  application 
of  leeches  to  the  alse  nasi.  A  simple  but  most  effective  remedy  is  the  use 
of  mustard  foot-baths  frequently  given. 

To  relieve  the  cerebral  hyperaemia,  calomel  in  ^/iQ-grain  doses,  and 
increased,  may  be  repeated  until  liquid  stools  have  been  produced.  It  is 
one  of  our  most  valuable  remedies  and  should  be  used  at  the  onset  of  a 
suspected  pneumonia.  Attention  to  the  stomach  and  bowels  will  frequently 
be  the  means  of  saving  the  life  of  the  patient.  I  insist  upon  a  loose  con- 
dition of  the  bowels,  and  if  the  same  cannot  be  produced  by  the  admin- 
istration of  calomel,  then  an  enema  should  be  given  by  flushing  the  colon 
as  often  as  once  in  twelve  hours  to  cleanse  the  parts.  When  children  are 
old  enough,  then  one  of  the  most  valuable  remedies  is  to  give  copious  drinks 
of  citrate  of  magnesia.  This  will  not  only  quench  the  thirst,  but  will  act 
as  a  laxative,  and  in  addition  thereto  stimulate  the  secretion  of  urine. 
We  find,  therefore,  that  the  emunctories  require  especial  stimulation  and 
attention  during  the  course  of  lobar  pneumonia. 

In  no  disease  is  strychnine  more  valuable  than  during  the  course 
of  pneumonia.  Very  small  doses  of  only  ^/goo  or  Vioo  grain,  repeated 
every  hour,  may  be  given  without  fear  during  the  progress  of  this  dis- 
ease.    The  question  of  stimulation  is  one  of  individuality.     Each  case 


476  THE  INFECTIOUS  DISEASES. 

must  be  treated  on  its  own  merits  and  the  individual  condition  studied. 
When  the  heart's  action  is  feeble  and  the  pulse  is  thready,  whisky  must 
be  given.  In  some  cases  five  to  thirty  drops  of  good  whisky  may  be 
given  as  often  as  every  half-hour  until  the  pulse  responds  to  the  stim- 
ulant. I  frequently  combine  strychnine  with  whisky.  In  other  cases 
champagne  in  half-drachm  or  drachm  doses  will  be  found  far  more 
effectual.  Some  children  object  to  the  taste  of  whisky  or  champagne,  but 
will  take  a  sweetened  wine.  In  such  cases  give  good,  old  Tokay  in  half- 
drachm  doses  as  often  as  is  required.  When  there  is  an  aversion  to  the 
taking  of  medicine  or  if  the  child  rebels  against  stimulation  by  the  mouth 
and  it  is  urgently  called  for,  then  half  a  teacupful  of  hot  water,  temperature 
of  100°  P.  to  105°  F.,  to  which  a  teaspoonful  of  either  whisky  or  alcohol  is 
added,  may  be  thrown  into  the  colon  by  means  of  a  colon  tube.  When  inani- 
tion exists,  as  in  the  septic  type  of  pneumonia,  the  Murphy  drip,  using  nor- 
mal saline  solution,  is  indicated.  Hypodermic  medication  must  not  be 
overlooked,  and  frequently  it  is  wise  to  use  whisky,  ether,  or  spirits  of  cam- 
phor. A  valuable  method  of  giving  camphor  hypodermically  is  by  inject- 
ing camphorated  oil,  from  5  to  15  minims.  Musk  is  one  of  our  best  cardiac 
stimulants,  and  if  the  pulse-rate  is  feeble  it  may  be  given  in  1-  to  5-  drop 
doses,  repeated  in  three  or  four  hours,  if  necessary. 

Hygienic  Treatment :  Boom  Temperature. — One  of  the  most  impor- 
tant factors  is  the  regulation  of  the  temperature  of  the  room.  Every  child 
having  a  pneumonia  should  be  put  into  a  room  having  a  temperature  of  65° 
to  70°  P.  An  equable  temperature  should  be  maintained,  as  the  same  is 
very  grateful  during  the  febrile  stage  of  this  disease.  Fresh  air  should  al- 
ways be  admitted. 

Oxygen. — When  severe  dyspnoea  occurs  and  if  cyanosis  exists,  then 
oxygen  inhalations  may  be  required.  Under  these  conditions  several  res- 
pirations should  be  given  every  few  minutes  until  the  lips  lose  their  cyanotic 
appearance  and  again  have  their  natural  color. 

Sponge  Baths. — The  surface  of  the  body  should  be  sponged  with  tepid 
water  every  day.  Equal  parts  of  alcohol  and  water  are  grateful  to  the 
patient,  and  should  be  used  every  hour  if  the  temperature  requires  it.  If, 
however,  the  temperature  is  not  high,  then  a  sponge  bath  to  which  a  little 
alcohol  has  been  added  will  be  grateful,  and  may  be  given  every  morning 
and  evening. 

Another  valuable  means  of  reducing  the  temperature  is  by  sponging 
•every  hour  with  acetic  ether.  This  must  be  cautiously  used,  owing  to  its 
volatile  and  inflammable  tendencies. 

The  Oil-silh  Jacket. — This  jacket  is  valuable  when  we  desire  a  dia- 
phoretic effect.  It  also  prevents  the  chilling  of  the  surface  of  the  lung  by 
maintaining  a  uniform  temperature.  The  details  of  making  this  jacket 
can  be  found  in  the  article  on  "Broncho-pneumonia,"  page  434. 


TUBERCULOUS  PNEUMONIA.  477 

Dietetic  Treatment. — As  previously  stated,  the  prognosis  in  this  con- 
dition depends  on  the  amount  of  food  the  patient  will  take.  A  milk  diet 
should  be  prescribed.  Buttermilk,  kumyss,  zoolak,  rice  and  milk,  farina 
and  milk,  oatmeal  and  milk,  and  cold  foods,  such  as  cornstarch  pudding, 
rice  pudding,  and  tapioca  pudding,  are  very  grateful.  If  the  child  is  very 
thirsty  and  is  over  2  years  old,  ice  cream  may  be  permitted  very  sparingly. 
This  is  very  grateful  to  the  little  patient,  and  if  made  from  fresh  cream  is 
very  nutritious.  Concentrated  soups,  chicken  broth,  and  veal  broth  may 
be  permitted.  So  also  calf's  foot  jelly,  chicken  jelly,  albumin  in  the  form 
of  raw  white  of  egg,  to  which  some  sugar  is  added,  may  be  given.  A  soft- 
boiled  egg  or  raw  yolk  of  egg  with  sugar  may  also  be  given. 

The  interval  between  each  feeding  must  be  prolonged,  owing  to  the 
subnormal  condition  of  the  digestive  tract.  If  children  are  fed  from 
the  bottle,  or  if  they  are  nursing  babies,  then  they  should  be  fed  with  a 
longer  interval  than  previous  to  the  time  of  this  illness;  for  example,  if 
the  infant  has  been  given  the  breast  every  three  hours,  it  is  a  good  rule  to 
extend  the  nursing  time  to  three  and  one-half  or  four  hours,  if  it  is  pos- 
sible. In  this  manner  we  will  not  only  aid  in  the  assimilation  of  the  food, 
but  frequently  prevent  stagnation  of  milk  which  had  been  previously  taken. 

Night  Feeding. — The  rule  which  governs  the  feeding  of  healthy  chil- 
dren cannot  be  applied  to  children  suffering  with  pneumonia.  During  the 
febrile  stage  large  quantities  of  liquids  are  demanded.  In  order  to  overcome 
the  cardiac  depression  good  nourishment  is  indicated.  A  nursling  suffering 
with  pneumonia  should  be  given  the  breast  several  times  during  the  night. 
Bottle-fed  infants  may  also  receive  some  nutrition  every  three  or  four  hours 
during  the  night.  A  favorable  termination  in  this  disease  can  only  be 
expected  when  the  depressed  vitality  is  stimulated  by  nutrition. 

Tuberculous  Pneumonia. 

There  are  four  pathological  conditions  which  illustrate  the  various 
stages  of  the  disease;  they  are:  first,  a  bronchitis  with  rhonchi  scattered 
through  the  chest;  second,  small  areas  of  consolidation  or  partial  consolida- 
tion; third,  complete  consolidation  with  bronchial  breathing,  dull  areas 
on  percussion;  fourth,  excavation  with  cavernous  or  amphoric  breathing. 

In  its  early  stages  the  disease  resembles  broncho-pneumonia. 

Cavities  are  frequently  found  post-mortem.  They  are  difficult  to  find 
in  children  under  3  years  of  age.  On  the  other  hand,  children  over  8  or  9 
years  have  cavities  which  can  be  recognized  as  early  as  in  the  adult. 

Holt  states  that  "the  reason  why  in  infancy  cavities  are  so  seldom  recog- 
nized during  life,  is  because  they  are  generally  small,  often  centrally  located, 
nearly  always  filled  with  thick  pus  or  cheesy  matter,  and  rarely  communicate 
freely  with  the  bronchi.     On  the  other  hand,  it  is  very  common  to  find 


478  THE  INFECTIOUS  DISEASES. 

signs  in  young  children  which,  if  heard  in  adults,  would  be  regarded  as 
almost  positive  evidence  of  a  cavity  although  none  is  present.  These 
signs  are  cracked-pot  resonance  and  cavernous  breathing.  They  are  not 
usually  due  to  bronchiectasis,  since  this  condition  belongs  to  chronic  cases, 
and  especially  to  older  children,  but  most  frequently  to  consolidation  about 
a  large  bronchus  superficially  situated,  viz.:  below  the  clavicle,  high  in  the 
axilla,  and  in  the  interscapular  region.  The  wide  area  over  which  this 
broncho-cavernous  breathing  is  heard  is  one  of  the  most  striking  points  of 
difference  from  the  signs  of  a  cavity." 

Course. — There  are  two  types  of  cases:  First,  rapid  cases  or  those 
terminating  very  quickly;  second,  those  assuming  a  chronic  course  (pro- 
tracted cases). 

1.  The  Rapid  Type. — The  pathological  process  is  a  bronchitis  affecting 
the  smaller  tubes  surrounded  by  areas  of  consolidation.  These  lesions  are 
the  same  as  are  found  in  broncho-pneumonia.  The  temperature  curve  is  fre- 
quently the  same  as  found  in  broncho-pneumonia,  ranging  between  100°  and 
104°  F.  The  areas  of  consolidation  are  more  frequently  found  in  the  upper 
lobes.  There  is  also  broncho-vesicular  breathing  and  bronchophony.  Per- 
cussion note  shows  slight  dullness.  The  cough  may  assume  a  paroxysmal 
character  similar  to  whooping-cough.  Convulsions  and  frequently  menin- 
geal symptoms,  such  as  a  slowness  of  the  pulse  or  Cheyne-Stokes  breathing, 
will  show  the  extension  of  the  disease  to  the  brain. 

2.  Those  Assuming  a  Chronic  or  Protracted  Course. — The  duration 
of  this  form  of  the  disease  may  be  between  one  and  six  months.  Some  cases 
may  last  but  three  months.  This  is  the  most  common  type  of  the  disease 
seen.  Cases  are  frequently  seen  following  measles,  whooping-cough,  pneu- 
monia, or  diphtheria.  Those  cases  I  have  seen  ended  fatally  within  three  or 
four  months.  There  is  usually  a  slight  improvement  after  the  second  or 
third  week  of  this  disease.  The  temperature  falls  and  the  physical  signs 
seem  to  disappear.  As  a  rule  the  disease  reappears  with  more  violent  symp- 
toms, and  emaciation,  fever,  and  sweating  continue  until  the  end.  The 
temperature  curve  is  not  regular.  In  some  cases  it  ranges  between  99°  and 
101°  F.  Other  cases  will  have  a  much  higher  temperature,  the  thermometer 
registering  104°  F.  frequently.  Expectoration  is  rarely  seen  in  young 
infants,  as  they  invariably  cough  and  swallow  the  same.  The  breathing 
is _  usually  labored;  hence  dyspnoea  is  almost  always  present.  When  we 
have  Cheyne-Stokes  breathing,  or  irregular  breathing,  with  a  slow  pulse, 
then  cerebral  complication  should  be  suspected. 


CHAPTER  IV. 

CHRONIC  PULMONARY  TUBERCULOSIS    (TUBERCULOUS 
BRONCHO-PNEUMONIA). 

This  condition  is  rarely  found  in  infants  and  very  young  children. 
When  chronic  pulmonary  tuberculosis  is  noted  it  is  usually  seen  in  children 
after  the  sixth  or  eighth  year.  ' 


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Fig.  1.51. — Fever  curve  during  the  early  period  of  Chronic  Pulmonary 
Tuberculosis.  The  daily  excursions  are  slight,  and  generally  range  between 
102°  and  104°  F.     (Original.) 


Fig.  1.52. — Temperature  curve  during  the  fifth  month,  when  the  disease 
is  more  extended  and  softening  has  taken  place  with  the  formation  of  cavi- 
ties. The  temperature  is  more  hectic  in  character.  The  morning  tempera- 
ture may  be  normal  or  subnormal,  while  the  evening  temperature  ranges 
between  103°  and  105°  F.     (Original.) 

Pathology. — Osier  states  that  small  cavities  are  by  no  means  rare  in 
chronic  pulmonary  tuberculosis  of  children,  but  very  large  excavations  are 
rare;  thus  in  265  cases  noted  by  Barthez  and  Sanne  there  were  77  cases 

(479) 


480 


THE  INFECTIOUS  DISEASES. 


with  excavation,  chiefly  in  the  upper  lobes.  In  the  analysis  by  Leroux  of 
the  cases  of  the  late  Parrot,  in  219  children  under  2  years  of  age, 
there  were  57  instances  in  which  cavities  existed.  In  five  of  these  the 
children  were  under  three  months.  In  long-standing  cases  hard,  firm, 
fibrous  tubercles  are  found,  and  sometimes  cutaneous  nodules.     The  pri- 


Fig.  153. — Chronic  Nodular  Tuberculous  Broncho-pneumonia,  {a,  h, 
c,  d)  tuberculous  foci  of  variable  size  and  shape,  corresponding  to  the  in- 
filtrated alveolar  system;  (e)  transverse  section  through  an  infiltrated 
occluded  bronchiole;  (f )  small  arterial  branch;  (g)  group  of  nodules  under- 
going coalescence;  (h)  small  unaltered  bronchus;  (fc)  artery.  X  6. 
(Ziegler.) 


mary  lesion  in  a  great  majority  of  instances  is  a  tuberculous  broncho- 
pneumonia, taking  its  origin  in  the  smaller  bronchioles,  leading  to  peri- 
bronchial nodules  and  subsequent  peribronchial  alveolitis.  The  lesions  are 
similar  to  those  met  with  in  tuberculosis  of  adults — miliary  tubercles, 
J)eribronchial  nodules,  caseous  blocks,  areas  of  softening  and  of  fibroid 
induration,  and  cavities  of  various  sizes.    We  do  not  see  so  frequently  the 


PULMONARY  TUBERCULOSIS.  481 

invasion  of  the  lung  from  the  apex  downward.  The  chief  seat  of  disease 
may  be  in  the  central  portion  of  the  lung,  or  even  at  the  base.  In.  tuber- 
culosis of  the  lymph  glands  the  groups  along  the  trachea  and  about  the 
bronchi  may  be  greatly  enlarged  and  caseous,  forming  on  section  a  very 
striking  feature  in  the  chronic  pulmonary  tuberculosis  of  children. 

Symptoms. — Chronic  pulmonary  tuberculosis  in  the  child  presents  the 
same  symptoms  as  in  the  adult.  Usually  a  broncho-pneumonia  will  first  be 
encountered,  or  the  symptoms  present  will  resemble  those  of  a  broncho- 
pneumonia. When  fever  persists  and  there  are  evidences  of  a  general 
breakdown,  such  as  malaise,  loss  of  appetite,  and  emaciation  with  or  with- 
out cough,  then  this  condition  must  be  suspected.  When  these  children 
expectorate,  the  same  resembles  that  seen  in  adults.  Tubercle  bacilli  have 
frequently  been  found  in  the  expectoration  of  cases  under  my  care.  Blood 
spitting  in  which  the  mucus  is  blood-stained  has  been  seen  by  me.  The 
blood  is  bright  red  in  color.  Epistaxis  is  sometimes  seen  during  the  course 
of  the  disease.  The  temperature  ranges  between  100°  and  103°  F.  in  the 
beginning  of  the  disease;  later  on  it  assumes  the  real  hectic  character; 
thus,  the  temperature  may  be  99°  to  100°  F.  in  the  morning,  and  103°  to 
105°  F.  in  the  evening. 

Pleuritic  pains  are  complained  of  in  various  parts  of  the  chest.  There 
is  marked  dyspnoea  and  frequently  cyanosis.  Osier  states  that  some  cases 
do  not  have  any  pain  throughout  the  course  of  the  disease.  A  general 
emaciation  associated  with  muscular  weakness  and  anaemia  is  usually  seen 
later  in  the  disease.  Tubercular  ulceration,  of  the  intestine  will  frequently 
cause  diarrhoea.  In  a  child  seen  by  me  with  chronic  tuberculosis  of  the 
lungs,  a  general  anasarca  was  present. 

Katie  B.,  8  years  old,  has  been  a  very  delicate  child.  She  was  breast-  and 
bottle-  fed,  and  lived  in  a  tenement  house. 

Family  History. — 'The  father  was  a  drunkard  and  did  not  support  his  family; 
the  mother  is  a  frail,  ansemic  woman,  although  no  evidence  of  pulmonary  disease 
could  be  found.  The  child  was  late  in  walking,  late  in  teething,  and  late  in  talking. 
Distinct  evidence  of  rickets  of  the  bones  was  everywhere  noted.  When  4  years 
old  the  child  had  measles,  complicated  with  broncho-pneumonia,  after  which  a 
cough  remained.  Tliree  months  after  the  measles  the  child  still  coughed  and 
showed  evidences  of  malnutrition.  The  cough  persisted  in  spite  of  codliver-oil, 
malt  extract,  and  iron,  which  were  liberally  given.  As  the  family  was  poor, 
they  could  not  take  the  child  to  the  country  for  a  complete  change  of  air.  I  did 
not  see  the  case  again  for  two  years,  when  I  saw  it  through  the  courtesy  of  Dr. 
John  H.  Wurthman.  At  this  time  she  had  a  cavitj^  at  the  apex  of  the  right  lung,  was 
terribly  emaciated,  and  complained  of  pain  on  breathing  and  suffered  with  marked 
dyspnoea.  Pleuritic  friction  sounds  were  heard  over  small  areas  of  the  chest  on 
both  sides.  The  child  had  haemoptysis,  besides  a  purulent  expectoration.  Tubercle 
bacilli  were  fouaid  in  the  sputum.  She  died  after  a  violent  haemorrhage,  from 
exhaustion  and  heart-failure. 

The  treatment  is  the  same  as  described  for  acute  tuberculosis. 

31 


483  THE  INFECTIOUS  DISEASES. 


Pulmonary  Gangrene. 

This  condition^  fortunately,  is  very  rare. 

Diagnosis. — This  is  made  by  the  characteristic  foul  odor  of  the  breath 
and  the  expectorated  gangrenous  material.  I  have  seen  a  case  of  this  kind 
during-  my  summer  service  at  the  Willard  Parker  Hospital  in  a  child  that 
suffered  with  laryngeal  diphtheria  complicated  by  broncho-pneumonia.  The 
septic  condition  dragged  on  for  weeks.  There  was  a  very  putrid  odor  to 
the  breath.  The  child  finally  died  of  sepsis.  As  a  rule  the  diagnosis  can 
only  be  made  post-mortem. 

Treatment. — Eestorative  treatment,  consisting  of  light,  nutritious  diet, 
should  be  given  and  stimulants  liberally  used.  Steam  inhalations  impreg- 
nated with  beechwood  creosote  will  modify  the  odor.  Creosote  carbonate 
can  be  given  with  the  food  in  5-  to  10-  minim  doses,  several  times  a  day. 


CHAPTER  Y. 

ACUTE  TUBERCULOSIS    (MILIARY  TUBERCULOSIS ).i 

Tuberculosis  is  a  specific  infectious  disease  caused  by  invasion  of  the 
tubercle  bacillus.    The  disease  is  disseminated  by  the  same. 

Etiology. — Acute  miliary  tuberculosis  is  frequently  seen  in  very  young 
children.  I  have  seen  cases  in  bottle-fed  infants  under  1  year  of  age.  It 
is'  also  frequently  associated  with  tubercular  meningitis.  As  a  rule  it  fol- 
lows those  diseases  which  devitalize  the  system,  such  as  the  acute  infec- 
tious diseases.  In  prolonged  diseases  affecting  the  air  passages,  tubercu- 
losis frequently  follows. 

Cows'  Milk. — The  majority  of  cases  of  tuberculosis  are  found  in  chil- 
dren brought  up  by  artificial  feeding.  This  implies  that  such  children 
received  cows'  milk.  The  dangers  of  infection  by  or  with  the  tubercle 
bacillus  can  usually  be  excluded  inasmuch  as  nearly  every  woman  boils  the 
milk.  The  more  modern  woman  of  to-day,  instead  of  boiling  cows'  milk, 
submits  the  food  to  a  steaming  process,  either  by  using  a  sterilizer  or  a 
pasteurizer.  The  result  is  the  same,  namely,  the  destruction  of  pathogenic 
bacteria  of  all  kind,  including  the  tubercle  bacillus.  Such  artificial  feeding 
with  cows'  milk  frequently  results  in  gastro-intestinal  derangement.  Dys- 
peptic attacks  rob  the  system  of  food  required  for  the  nutrition  of  bone, 
muscle  and  other  organic  structures.  When  such  conditions  persist  then 
poor  foundations  are  formed,  resulting  in  rickets  or  marasmus.  The  tuber- 
cle bacillus  easily  gains  entrance  where  subnormal  conditions  prevail,  and 
secures  a  foothold  that  ultimately  develops  tuberculosis. 

Woman's  Milk. — Human  milk  is  intended  by  nature  for  the  nutrition 
of  infants.  It  offers  decided  prophylactic  substances  to  the  nurslings,  for 
exajnple:  .  the  nursing  infant  is  very  rarely  afflicted  with  diphtheria  or 
similar  infectious  diseases.  This  is  most  probably  due  to  the  immunity 
conferred  by  human  serum  and  the  antibodies  or  bacteriolysins  which  the 
serum  contains  during  the  nursing  period.  This  also  accounts  for  the 
rarity  of  pulmonaiy  tuberculosis  in  children  reared  on  woman's  milk.  The 
value  of  human  milk  has  frequently  been  noted  by  me  while  studying  this 
question  in  a  children's  clinic  patronized  by  people  living  in  the  most  con- 
gested district  of  New  York  City. 

The  statistics  of  my  cases  of  tuberculosis  from  the  children's  service 
of  the  German  Poliklinik  in  New  York  City  are  very  interesting.  Five 
thousand  children  were  examined  at  random  for  the  presence  of  tubercular 

'■Tuberculosis  of  the  bones,  joints,  and  glands  are  described  under  separate 
articles. 

(483) 


484  THE   INFECTIOUS  DISEASES. 

lesions.  More  than  4900  cases  out  of  this  number  showed  no  sign  of  pul- 
monary disease;  1700  of  these  cases  suffered  with  adenoids,  phar^^ngeal 
disease,  catarrh  of  the  naso-pharyngeal  tract,  or  infectious  conditions  due 
to  poor  ventilation  and  general  unsanitary  surroundings.  The  cases  were 
taken  in  children  from  the  first  to  the  tenth  year  inclusive;  59  cases  out 
of  this  whole  number  showed  distinct  evidence  of  pulmonary  tuberculosis. 
Only  9  cases  of  this  whole  number  showed  the  presence  of  tubercle 
bacilli  in  the  sputum.  The  difficulty  in  procuring  sputum'  was  an  obstacle 
in  making  niore  frequent  examinations.  Forty-three  cases  of  this  number 
had  bone  and  joint  tuberculosis  in  addition  to  evidences  in  the  lungs.  In 
two  cases  tubercular  empyema  was  found.  Five  of  these  59  cases  had 
Pott's  disease. 

Table  No.  43. — Table    showing  Manner  of  Feeding  in  59  Consecutive  Cases  of 
Tuberculosis,  among  the  Poor. 
Manner  of  Feeding.  Number  of  Cases. 

Breast  milk    (human  milk) 2 

Cows'  milk  37 

Condensed  milk 18 

Modified  milk  (laboratory)    2     ' 

Tuberculosis  in  children  is  so  closely  allied  to  scrofulosis  that  a  great 
many  authors  believe  them  to  be  identical.  There  certainly  are  a  great 
many  characteristics  common  to  both.  On  the  other  hand  a  close  scrutiny 
of  the  pathology  of  the  disease  will  show  them  to  be  distinctly  separate. 
That  scrofulosis  will  frequently  be  the  medium  through  which,  later  on, 
tuberculosis  develops,  is  well  known  and  recognized. 

"In  the  tuberculosis  of  the  new-born  evidence  shows  that  the  maternal 
ovum  may  be  infected  from  the  mother,  or  by  the  paternal  seminal  fluid; 
later  the  embryo  may  be  infected  by  the  placental  route  or  amniotic  fluid 
when  the  mother  is  tubercular.  These  modes  of  infection,  while  theoretic- 
ally possible  and  occasionally  actually  authenticated,  are  nevertheless  ex- 
tremely infrequent  in  practice.  By  whichever  of  the  above-mentioned  routes 
the  bacillus  has  gained  entrance  to  the  foetal  organism,  there  is  no  doubt 
that  it  may  invade  it  and  remain  latent  therein  for  an  indefinite  period. 
Unless  the  bacilli  are  actually  found  within  the  tissues,  it  is  ex- 
tremely difficult  to  uphold  the  view  that  the  infection  has  not  been  acquired 
after  birth." 

The  influence  of  raw  meat  on  the  evolution  of  experimental  tubercu- 
losis has  been  described  by  Chantemesse  and  Cornil. 

Kichet  and  Hericourt  published  experiments  showing  the  beneficial 
effects  of  raw  meat  in  tuberculosis  of  dogs.  Their  observations  were 
open  to  the  objection  that  the  quantity  of  meat  given  was  not  measured, 
and  that  the  good  effect  obtained  might  have  been  due  merely  to  the  fact 


TLTBERCULOSIS. 


485 


that  the  dogs  preferred  larger  quantities  of  raw  meat  than  they  would 
have  eaten  of  boiled.  To  exclude  this  influence  the  following  experiments 
were  made.  Six  couples  of  dogs,  each  of  the  same  weight  and  appearance, 
were  taken.  One  of  each  couple  was  fed  with  boiled  meat  to  satiety,  the 
other  was  given  an  equivalent  quantity  of  raw  meat.  Both  were  inoculated 
in  the  vein  of  the  leg  with  tuberculosis.  The  dogs  fed  with  boiled  meat 
died  at  intervals  varying  from  three  weeks  to  four  months.  The  necropsies 
showed  general  tuberculosis,  more  or  less  voluminous  caseous  granulations, 
and  advanced  fatty  degeneration  of  the  liver.  Those  fed  on  raw  meat  were 
killed  at  the  same  time.  They  were  all  plump ;  they  showed  less  numerous 
tubercles  than  did  the  others,  and  less  voluminous  and  less  caseous  granu- 
lations. In  another  experiment  a  dog  was  inoculated  with  tuberculosis  and 
given  750  grams  daily  of  raw  meat.  He  preserved  his  strength,  weight,  and 
healthy  appearance.  He  was  killed  at  the  end  of  twelve  months.  The 
necropsies  showed  a  small  number  of  tubercles  in  the  viscera  and  tuber- 
cular interstitial  nephritis.  He  was  on  the  way  to  recovery.  Two  monkeys 
were  inoculated  with  tuberculosis.  One  was  fed  on  the  ordinary  diet,  and 
died  at  the  end  of  33  days  of  general  tuberculosis;  the  other  was  fed  on  raw 
meat  for  15  days  before  the  innoculation,  and  lived  for  49  days. 
Chantemesse  and  Cornil  therefore  conclude  that  the  utility  of  raw  meat 
diet  in  tuberculosis  consisted  not  in  overfeeding,  hut  in  the  anti-tubercidous 
quality  of  the  diet. 

The  transmissibility  of  tuberculosis  by  means  of  drinking  milk  from 
cows  whose  udders  are  tuberculous,  is  admitted  by  a  great  many  authors. 

Behring  believes  that  milk  infection  remains  latent  for  years  and  then 
develops  ti;berculosis.  This  he  states  accounts  for  the  absence  of  the  dis- 
ease in  very  young  infants. 

Koch  is  authority  for  the  statement  that  "bovine  tuberculosis  is  an 
entirely  different  disease  from  human  tuberculosis,  and  cannot  be  trans- 
mitted from  a  cotu  to  a  human  being." 

"Westenhoeffer  believes  that  caries  of  the  teeth  and  inflamed  gums,  as 
seen  during  dentition,  permit  the  invasion  of  the  tubercle  bacillus  into 
the  lymph  channels  of  the  neck,  resulting  in  cervical,  bronchial,  retrosternal, 
tracheo-bronchial,  and  finally  mesenteric  tuberculosis.^ 

Chiari,  of  Vienna,  and  Freudenthal.  of  Xew  York,  believe  that  the 
retropharynx  which  harbors  adenoids  is  the  point  of  entrance  of  the  tubercle 
infection.  This  view  has  always  been  held  by  me,  inasmuch  as  tubercular 
meningitis  results  most  probably  from  an  extension  upward  from  the 
pliaryn.v,  and  downward,  the  infection  enters  through  the  cervical  glands. 

Contact  of  the  delicate,  perhaps  abraded,  skin  or  mucous  membrane 


^Berlin  Klin.  Woch..  February  15.  1904. 


486 


THE   INFECTIOUS  DISEASES. 


of  the  young  infant  with  tuberculous  sputum  may  result  in  inoculation,  as 
has  been  reiDeatedly  shown  in  connection  with  ritual  circumcision. 

The  interesting  observations  of  Lehmann  show  that  sucking  the  wound 
after  the  ritual  circumcision  of  Jewish  children  has  caused  tuberculosis. 
Baginsky  reports  a  case  of  the  transmission  of  tuberculosis  to  the  eyebrow 
of  a  child  by  a  tuberculous  person.  That  tuberculosis  may  be  transmitted 
by  the  process  of  vaccination  on  the  arm  cannot  be  disputed. 

There  must  be  a  certain  disposition  or  predisposition  to  the  develop- 
ment of  this  disease.  Other  factors  which  are  prominent  in  this  connec- 
tion are  poor  hygienic  apartments;  rooms  in  which  sunshine  is  absent  and 
in  which  foul  air  stagnates  will  certainly  lower  the  normal  resisting  power 
of  any  and  all  individuals.  When  a  child  has  passed  through  an  acute 
infectious  disease  which  has  already  lowered  its  vitality,  then  an  infection 
with  tuberculosis  is  more  easily  accomplished.  Among  such  diseases  which 
predispose  to  the  development  of  tuberculosis  are  whooping-cough  and 
measles.  The  same  is  also  true  in  exhaustive  diseases  which  drain  the 
vitality  of  children  for  a  long  time,  as,  for  example,  after  a  prolonged 
attack  of  summer  complaint.  The  disease  frequently  accompanies  the 
nursing  period,  hence  even  the  youngest  child  may  become  infected. 

Tuberculosis  has  so  great  a  tendency  to  generalize  itself  in  children 
that  the  question  of  the  primary  infection  is  not  to  be  settled  by  the  mere 
frequency  of  the  lesions.  The  fact  that  children  swallow  their  sputa  is  to 
be  kept  in  mind.  There  is  no  question  as  to  its  infectiousness,  while  that 
of  infected  milk  in  the  human  species  has  not  been  absolutely  demonstrated. 
Still's  statistics  show  that  in  25  cases  taken  consecutively,  of 
children  under  3  years,  who  did  not  expectorate,  intestinal  lesions  were 
found  in  19,  while  in  a  similar  series,  aged  between  3  and  12,  they  were 
found  in  only  10.  It  would  thus  appear  that  autoinfection  by  the  sputa  in 
infants  is  a  matter  of  serious  importance. 

Bacteriology. — The  germ  can  be  traced  to  the  blood  and  also  the  cells 
of  the  blood-vessels.  This  has  been  proven  through  studies  made  by  Dou- 
trelepont,  Lustig,  Meisels,  and  Weigert. 

Demme  found  this  specific  germ  in  pus  exuding  from  an  eczema;  the 
same  is  true  about  pus  in  otitis.  Tuberculous  affections  of  the  tongue,  of 
the  nasal  mucous  membrane,  of  the  thorax  and  tuberculous  swellings  on 
the  lips  of  young  girls  have  been  described  by  Volkmann.  Primary  tuber- 
culosis of  the  thymus,  of  the  heart,  and  of  the  vaginal  mucous  membrane 
have  been  published  by  Demme.  A.  Baginsky  has  described  a  series  of 
cases  of  tuberculous  perityphlitis,  peritonitis,  and  enteritis.  Tuberculosis 
of  the  testicles  in  children  lias  been  seen  and  observed  by  him.  The  so- 
called  scrofulous  inflammatory  conditions  of  the  Joints  and  suppurative  dis- 
eases of  the  bones,  while  being  described  as  "scrofulous,"  are  usually  of  a 
tuberculous  nature.     The  internal  organs  suffer  from  the  invasion  of  the 


TUBERCULOSIS.  437 

tubercle  bacillus  in  this  connection.  The  lungs  and  the  pleura,  the  peri- 
cardium and  myocardium,  the  liver,  spleen,  and  kidneys,  the  coverings  of 
the  brain,  and  the  brain  itself  are  frequently  affected. 

The  question  of  the  transmission  of  the  tubercle  bacillus  is  one  that 
is  still  debatable.  Thus  Jani  reports  in  Virchow's  Archiv,  Bd.  103,  p.  522, 
that  the  seminal  fluid  of  tuberculous  persons  contains  tubercle  bacilli.  The 
cases  of  tubercles  in  the  foetus  are  described  by  Johne  and  Armanni.^  Bang, 
Lehmann,  Bircli  Hirschfeld,  Eindfleisch,  and  Kossel  are  among  those  who 
have  reported  isolated  cases  of  tuberculosis  directly  transmitted  from 
parent  to  child.  Hochsinger  recently  reported  3  cases  which,  he  describes 
as  congenital  tuberculosis.  These  cases  were  associated  with  syphilis,  and 
he  believes  that  this  disease  is  far  more  frequently  transmitted  than  is  gen- 
erally recognized.    Thus  it  appears  from  the  studies  of  Brandenberg,  Lesage, 


Fig.  154. — Tiibercle  Bacilli  and  Micrococcus  Tetragenus  {sputum). 
Gabbet's  stain,  Leitz  ocular  I,  oil  immersion  Vi2-  (d)  tubercle  bacilli;  (h) 
micrococcus  tetragenus.      (Lenhartz-Brooks). 

and  Wolff  that  the  placenta  is  an  exceedingly  valuable  culture  medium  for 
this  specific  micro-organism,  and  thus  they  account  for  the  com- 
parative freedom  of  the  foetus  born  to  a  tuberculous  mother. 

Cornet  and,  more  recently,  Fliigge  made  extensive  investigations  show- 
ing the  means  of  dissemination  of  the  tubercle  bacillus.  We  are  indebted 
to  them  for  our  knowledge  regarding  the  danger  of  sputum  of  a  phthisical 
patient,  and  also  regarding  the  manner  of  transmission  of  this  disease. 

How  susceptible  very  young  children  are  can  be  shown  by  a  case  pub- 
lished by  Wassermann,^  in  which  he  reports  the  transmission  of  tubercu- 
losis to  a  child  six  weeks  old  by  being  in  contact  in  the  same  room  with  a 


^  Tenth  International  Medical  Congress,  Bd.  5. 
^  Zeitschi-if t  f .  Hygiene,  p.  353. 


488  THE  INFECTIOUS  DISEASES. 

phthisical  patient  for  eight  days.  Ivitasato^  reports  the  fact  that  tubercle 
bacilli  die  rapidly  in  the  sputum,  and  he  therefore  does  not  believe  the 
danger  of  the  transmissibility  of  tuberculosis  is  as  great  as  has  been  claimed. 
That  contact  with  tuberculous  patients  is  a  very  serious  matter  can  be  seen 
by  a  study  of  the  literature. 

Mother's  milk  has  been  closely  studied  and  the  possibility  of  infection 
through  this  channel  cannot  be  denied. 

Pathological  Anatomy. — "We  are  indebted  to  Bayle,  Buhl,  Laennec,  and 
Yirchow  for  the  division  and  study  of  the  pathological  anatomy  of  this 
disease.  These  authors  divide  the  conditions  into  two  distinct  j)arts :  First, 
cheesy  pneumonia;  second,  the  real  miliary  tuberculosis.  By  the  cheesy 
pneumonia  is  meant  that  form  of  a  chronic  destructive  process  ending  in 
cheesy  necrobiosis.  By  the  miliary  tuberculosis  is  meant  that  form  of  dis- 
ease commencing  as  a  tiny  nodular  swelling,  which  starts  in  the  connective 
tissue  and  is  associated  with  the  lymph  bodies,  having  a  tendency  to  form 
broken-down  cheesy  masses.  The  patholog}^  of  this  disease  can  certainly  be 
associated  with  no  greater  name  than  that  of  Yirchow,  to  whom  we  are  in- 
debted for  the  bulk  of  our  knowledge  of  this  disease. 

The  tubercle  is  a  small,  grayish-white,  translucent,  sometimes  yellowish 
body.  The  greatest  masses  consist  of  small,  round  cells  about  the  size  of 
a  red  blood-corpuscle,  and  large  cells  resembling  epithelium.  There  are 
also  giant  cells.  The  giant  cell,  as  a  rule,  can  be  found  in  the  middle  of 
these  tubercles  and  is  so  closely  identified  with  this  condition  that  it  has 
been  looked  upon  as  characteristic  of  this  disease. 

The  growth  of  the  tubercle  consists  in  the  development  of  new  masses 
arising  from  the  giant  cells.  In  these  giant  cells  there  are  no  blood-vessels, 
and  as  there  is  no  nutrition  they  easily  break  down  and  form  what  is  later 
on  the  beginning  of  cheesy  masses,  which,  by  absorption  and  a  melting 
process,  are  the  real  beginnings  of  cavities.  At  times  these  masses  result  in 
chalk  deposits.  The  question  of  the  specific  origin  of  the  disease  has  been 
finally  settled  by  the  investigations  of  Koch,  who  proved  the  specific  micro- 
organism known  as  the  tubercle  bacillus  to  be  the  j^athological  factor. 

Biedert  found  16  cases  of  primary  intestinal  tuberculosis  among  3104 
post-mortems. 

Heller  found  7.4  per  cent,  of  primary  tuberculosis  among  714  post- 
mortems in  diphtheria,  and  a  total  of  19.6  per  cent,  of  all  varieties  of 
tuberculosis  among  these  714  cases. 

Orth  states  that  primary  intestinal  tuberculosis  is  exceedingly  rare  in 
Berlin  because  of  the  universal  use  of  sterilized  or  boiled  milk.^ 


^  Zeitschr.  f.  Hygiene,  Bd.  9,  1892,  Heft  3. 

- 1  have  collected  and  described  a  series  of  important  observations  on  the 
association  of  cows'  milk  with  tuberculosis.  The  pathologic  of  the  cow's  udder  and 
the  milk  ducts  are  also  described.      (See  chanter  on  "Cows'  Milk.'") 


TUBERCULOSIS. 


480 


Fig.  155.— Tuberculosis.  Horizontal 
section  through  the  tuberculous  lower  lobe 
of  the  right  lung  of  a  two-year-old  child. 
(a)  caseous  focus  in  the  region  of  the  an- 
terior border;  (b)  nontuberculous  poster- 
ior border;  (c)  transverse  section  of  bron- 
chus; (d,d^)  caseated  lymph  glands;  (e) 
pulmonary  vein ;  (f)  point  of  adhesion  of 
the  vein  e  with  the  lymph  f/Jand  fZ';  (g) 
tubercle  in  the  lymph  vessels  of  the 
lung  parenchyma;  (h)  periarterial;  (i) 
peribronchial;  f-k)  perivenous  tubercles;  (I)  lymph  vessel  tubercles  of  the 
pleura ;  (iii)  tubercle  in  its  connective  tissue  of  the  hilus  of  the  lung.  X3. 
(Ziegler.) 


490 


THE   INFECTIOUS  DISEASES. 


Baginsky  reports  that  he  found  8  cases  of  tuberculosis  that  died  among 
871  nurslings  at  his  Berlin  hospital.  These  were  all  under  ten  months  of 
age.  On  the  other  hand  he  found,  among  266  children  in  the  second  yea'r, 
13  died  of  miliary  tuberculosis.  One  hundred  and  eighty-two  children  out 
of  611  died  of  miliary  tubercvilosis  between  the  age  of  2  and  4  years.  Out 
of  153  children  examined  between  the  age  of  4  and  6  years,  6  had  miliary 
tuberculosis. 


Fig.  156. — Acute  Pulmonary  Miliary  Tuberculosis  (Cut  Sui-face  of  the 
Lung.)  (a)  so-called  obsolete  tubercle  (old  encapsulated  caseous  focus),  (b) 
induration,  (cj  caseous,  partly  agminated  nodules  (transverse  section  of 
caseous  bronchi.)  (dj  submiliary  noncaseated  tubercle  in  the  true  lung 
tissue,  (ej  tubercle  of  the  pulmonary  pleura.  One  half  natural  size.  (Lang- 
erhans.) 

StilP  considers  these  facts  and  offers  some  interesting  statistics,  based, 
not  on  clinical  observation,  but  on  post-mortem  findings,  for  the  solution 
of  this  problem.  In  769  autopsies  of  children,  tubercle  was  found  in  269, 
or  35.2  per  cent.  Tuberculosis  was  the  actual  cause  of  deaths  in  252,  or  32.8 
per  cent.    From  those  statistics,  therefore,  it  can  be  roughly  estimated  that 


Clinical  Jouninl,  London. 


PLATE  XVTI 


Disseminated  pulmonary  tuliorculosis  Avitli  collapsed  right  lung  and  a  natural 
pneumothorax.    Child  four  years  old. 


TUBERCULOSIS.  491 

about  one-third  of  the  deaths  in  childhood  are  due  to  tuberculosis  in  one 
form  or  other.  While  children  are  thus  shown  to  be  specially  subject  to 
this  disease,  they  are  not  equally  so  at  all  ages,  for  Still  shows  that  up  to  the 
age  of  4  the  percentage  is  as  high  as  71,  and  between  4  and  8  is  still  22.5 ; 
after  8  it  diminishes  to  6.5.  Moreover,  the  greater  part  of  the  tuberculosis 
under  the  age  of  4 — 43.4  of  the  71  per  cent. — occuiTed  in  children  under 
2  years  of  age.  This  great  frequency  of  tuberculosis  in  infancy  has  been 
used  a^  an  argument  in  favor  of  the  idea  of  infection  through  milk,  the 
primary  lesion  being  in  the  digestive  tract.  It  is  true.  Still  says,  that  in- 
testinal tuberculosis  is  exceedingly  common  in  children;  it  existed  in  52 
per  cent,  of  his  cases  examined,  but  so  also  is  that  of  the  brain  and  meninges 
— 48  per  cent. — and  that  of  the  lungs  is  far  more  frequent — 78  per  cent. 

The  total  number  of  deaths  reported  as  due  to  consumption  in  the 
United  States  during  the  census  year  was  109,750,  of  which  53,626  were 
males  and  56,124  were  females  and  the  ratio  of  deaths  from  this  disease 
to  1000  deaths  from  all  Icnown  causes  was  109.9.  In  1890  the  correspond- 
ing ratio  was  122.3. 

The  death  rate  of  the  colored  from  consumption  was  nearly  three  times 
that  of  the  whites,  and  that  of  the  foreign  whites  was  much  higher  than 
that  of  the  native  whites.  For  the  last-mentioned  class  the  death  rate  for 
those  having  one  or  both  parents  foreign  was  also  much  higher  than  for 
those  of  native  parents. 

The  death  rate  of  males  from  tliis  disease  was  considerably  higher  than 
that  of  females. 

The  total  number  of  deaths  repoi-ted  as  due  to  consumption  in  the 
United  States  in  children  under  15  years  of  age,  during  the  census  years 
1890-1900,  was  8051,  of  which  3554  were  males  and  4497  were  females. 

The  death  rate  from  consumption  in  the  registration  States  was  higher 
in  the  District'  of  Columbia  (305.3),  which  was  due  mainly  to  the  large 
colored  population.  The  next  highest  rate  in  the  registration  States  was  in 
Rhode  Island,  where  it  was  195.3.  The  death  rate  from  this  disease  was 
higher  among  males  than  females  in  the  cities,  but  lower  in  the  rural  dis- 
tricts. Excluding  the  District  of  Columbia,  the  highest  occurred  among 
males  in  the  city  of  New  York  (265.3),  and  the  lowest  among  males  in  the 
rural  districts  of  Michigan. 

The  following  table  shows  that  the  death  rates  due  to  consumption  in 
white  persons  under  15  years  of  age  were  highest  in  those  whose  mothers 
were  born  in  Italy  (50.7),  in  France  (47.1),  and  in  "^other  foreign"  coun- 
tries (45.9)  ;  and  were  lowest  in  those  whose  mothers  were  born  in  Poland 
(11.4),  in  Bohemia  (13.2-),  and  in  Germany  (26.6). 

J.  Walker  Carr  reports  statistics  of  necropsies  on  tuberculous  children 
at  the  Victoria  Hospital.  He  found  79  in  which  the  disease  most  probably 
started  in  the  chest  and  20   in  which  it  seemed  to  have  begnn  in  the 


492 


THE  INFECTIOUS  DISEASES. 
Table  No.  44. 


Color  and  Birthplace  of  Mothers. 


Under  15  Tears. 


White   31.8 

Colored  246.0 

Mothers  born  in — 

United  States 27.5 

Ireland   42.2 

Germany     26.6 

England  and  Wales  27.2 

Canada   34.5 

Scandinavia 32.4 

Scotland   32.9 

Italy   50.7 

France    47.1 

HungaiT • 38.6 

Bohemia  13.2 

Russia    26.7 

Poland  11.4 

Other   foreign    45.9 


Table  Xo.  45. — Percentage  of  Deaths  per  1000  from  Consumption  in  ChiMren  from 
1   to  15  years  of  age    {United,  States). 


Age. 


1900 


Males. 


Under   1  year 

1  year 

2  years   ] 

3  years  i 

4  years   ! 

Under  5  years j 

5  to  9  years   

10  to  14  years   ' 


Females. 


Males. 


1890 


Females. 


IS.S 

17.8 

20.1 

16.5 

9.3 

9.6 

9.7 

10.9 

5.2 

4.S 

5.1 

5.0 

3.3 

4.0 

2.7 

3.6 

2.3 

2.2 

2.0 

2.8 

38.9 

38.4 

39.6 

38.8 

8.1 

13.2 

S.l 

11.7 

9.5 

24.7 

10.7 

27.2 

abdomen.  Here  the  relation  between  the  two  forms  of  infection  is  as 
1  to  4.  In  26  children  of  early  or  limited  tuberculosis,  the  thorax  alone 
was  affected  in  12  cases,  the  abdomen  in  T,  being  in  the  proportion  of  1  to 
1.7.  Of  53  tuberculous  children  under  2  years  of  age  the  disease  most 
probably  began  in  the  chest  in  43  and  in  only  5  certainly  in  the  abdomen, 
the  proportion  in  this  case  being  as  1  to  8.6.  Out  of  27  children  over  5 
years  of  age,  the  disease  began  in  the  chest  in  12,  in  the  abdomen  in  6,  the 
relation  being  as  1  to  2. 

Bollinger,  in  his  address  at  the  International  Tuberculosis  Congress, 
of  Berlin,  m  1899,  quoted  with  approval  the  record  of  autopsies  by  Heller 
(Kiel)  of  248  tuberculous  children.  In  45.5  per  cent,  of  the  cases  tuber- 
culosis  involved   the   mesenteric   Erlands.      From   these    it   was   concluded 


TL  liKKCl'LUSlS.  ^f,;^ 

that  milk  played  a  leading  role  in  the  so-called  transmitted  tuberculosis  of 
children. 

It  is  plain  from  what  has  been  said,  without  quoting  further  statistics, 
that  in  some  countries  where  bovine  tuberculosis  is  very  frequent,  there  is 
also  a  great  frequency  of  tuberculosis  in  children.  Bollinger  concludes  that 
'^"■'although  the  tuberculosis  of  cattle  and  swine  does  not  stand  in  the  first 
line  as  source  and  starting  point  of  human  tuberculosis,  nevertheless — con- 
sidering their  enormous  distribution  and  progressive  additions,  and  the  great 
danger  from  the  ingestion  of  the  milk  of  tuberculous  cows— they  are  cer- 
tainly for  humanity  the  most  important  and  the  most  dangerous  of  all 
animal  plagues,  and  deserve  the  most  earnest  attention  from  the  sanitarian 
and  the  state." 

Symptoms; — The  more  important  symptoms  noted  in  this  condition  are 
a  general  restlessness  with  a  rise  of  temperature.  Children  frequently  have 
little  or  no  cough,  but  some  difficulty  with  respiration  for  which  no  distinct 
physical  signs  can  ])e  found.  The  temperature  will  sometimes  rise  as  high 
as  103°  or  104°  F.,  or  it  may  suddenly  become  apyretic  and  assume  a  sub- 
normal tendency.  The  temperature  usually  seen  is  101°  F.  The  children 
appear  very  angemic  and  at  times  cyanotic,  mostly  on  the  cheeks  and  lips. 
Emaciation  usually  accompanies  this  "intermittent  type  of  fever."  To  the 
inexperienced,  the  beginning  of  a  miliary  tuberculosis  resembles  mostly  the 
clinical  picture  which  so  frequently  accompanies  intermittent  fever.  There 
usually  is  slight  swelling  of  the  peripheral  lymph  glands.  .  The  spleen  and 
liver  will  be  felt  enlarged.  .  The  urine  will  give  a  slight  diazo  reaction,  also 
an  indican  reaction.  Xeither  of  these,  however,  are  constantly  present.  We 
have  what  is  commonly  known  as  a  "pre-tubercular  anasmia,"  in  which  there 
is  a  general  tendency  to  hreakdown,  and  pallor  so  well  marked,  for  which 
there  is  no  distinct  group  of  symptoms.  When  such  profound  anajmia 
exists  with  slight  variations  of  temperature,  then  tuberculosis  may  be  in- 
ferred; hence  this  stage  is  regarded  by  some  clinicians  as  the  "pre-tuber- 
cular"  stage.  Occasionally  the  examination  of  the  chest  shows  catarrhal 
symptoms  and  rhonchi  as  accompany  an  ordinary  bronchitis.  There  is  an 
absence  of  bronchial  breathing  and  no  distinct  evidence  of  dullness  on  per- 
cussion. Frequently  these  symptoms  increase  in  severity.  Cyanosis  may 
accompany  this  condition  and  the  circulation  may  be  so  poor  as  to  show  cold 
feet  and  hands.  Death  occasionally  follows  this  condition.  The  clinical 
picture  here  given  is  the  one  that  is  frequently  seen  in  that  type  of  acute 
miliary  tuberculosis  running  a  malignant  and  very  short  colirse.  In  this 
condition  the  children  appear  very  pale  and  lose  weight.  There  is  distinct 
anorexia  which  alternates  with  hyperorexia.  Dyspeptic  symptoms,  such  as 
vomiting  and  diarrhoea,  may  alternate  with  constipation.  Such  children 
are  usually  very  sensitive  and  inclined  to  be  peevish  and  cry  on  the  slightest 
provocation. 


494  THE    INFECTIOUS    DISEASES 


» 


D'Espine's  Sign. — This  sign  is  of  great  importance  in  confirming  the 
diagnosis  of  t-uberciilosis  in  its  earliest  stage.  In.  children  old  enough  to 
repeat  the  words  "three  thirty  three"  the  echo  heard  of  the  last  word  is  very 
significant,  and  should,  when  present,  be  regarded  as  supporting  the  diag- 
nosis of  tuberculosis. 

D'Espine  studied^  a  series  of  infants  and  children  and  noted  that  the 
whispered  voice  is  not  heard  lower  than  the  seventh  cervical  spine 
posteriorly. 

If  the  lymph-nodes  are  enlarged  and  the  patient  whispers  "three  thirty 
three"  then  bronchophony  is  heard  over  the  upper  thoracic  spine  as  well. 

D'Espine's  sign  is  best  elicited^  when  the  arms  are  folded  well  across 
the  chest,  the  head  sharply  flexed,  and  the  patient  sitting  erect.  Firm  pres- 
sure should  be  made  with  the  stethoscope  as  patient  repeats  "three  thirty 
three."  When  the  sign  is  positive  the  final  "e"  of  the  last  word  persists  for 
a  moment  like  an  echo  after  the  phonation  ceases.  This  postphonal  quality 
is  the  significant  feature.  Young  children  can  often  repeat  the  "tree"  more 
easily  than  the  usual  phrase.  Occasionally  the  spoken  voice  or  cough 
brings  out  the  echoing  quality  more  than  the  whisper. 

A  study  of  the  above  symptoms  will  show  that  there  are  no  distinct 
typical  symptoms  which  can  be  laid  down  as  positively  diagnostic.  It  is 
for  this  reason  that  so  many  other  diseases  are  confounded  with  miliary 
tuberculosis  until  the  same  has  progressed  considerably.  When  there  is 
marked  cachexia  accompanying  nurslings  for  which  there  is  no  distinct 
reason,  and  especially  so  if  the  fever  accompanying  the  same  is  an  inter- 
m.ittent  type,  then  we  should  not  forget  the  possibility  of  our  dealing  with  a 
case  of  miliary  tuberculosis. 

Case  I.  A  child,  2  years  old,  was  brought  to  my  children's  clinic  at  the  New 
York  Post-Graduate  Medical  School  and  Hospital,  with  the  following  history:  She 
was  a  bottle-fed  infant  raised  on  condensed  milk.  The  bowels  were  always  con- 
stipated. Has  had  one  attack  of  cholera  infantum  when  eleven  months  old  which 
caused  emaciation  and  general  atrophy. 

Present  illness  dates  back  to  three  months  ago  when  child  had  measles  fol- 
lowed by  a  severe  broncho-pneumonia.  The  cough  has  persisted,  but  mostly  at 
night.     There  was  no  expectoration. 

Physical  Examination. — Examination  reveals  an  emaciated,  very  rachitic  child, 
pigeon-breasted,  with  decided  beaded  ribs.  There  is  also  a  kyphosis.  The  abdomen 
is  distended  (pot-belly).  The  superficial  veins  are  enlarged,  the  head  shows 
marked  frontal,  parietal,  and  occipital  rickets.  Cranio-tabes  is  also  present,  so 
that  we  can  safely  call  this  a  markedly  rachitic  case.  At  the  left  apex  there  were 
heard  coarse,  mucous  and  sonorous  rales,  also  prolonged  expiration.  The  right  lower 
lobe  had  several  areas  of  amphoric  breathing,  also  some  friction  sounds  and  prolonged 
'  harsh  expiration.  Percussion  note  was  dull.  The  morning  temperature  in  the  rectum 
was  101°  F.,  pulse  144,  respiration  40.  The  appetite  was  poor,  spleen  enlarged,  hands 
and  feet  cold,  and  the  child  perspired  freely. 

^D'Espine,  Bulletin  de  I'Acad.  de  Med.  Paris,  1907. 
-Stoll,  Amer.  Jour.  Dis.  of  Children,  Sept.,  1915. 


TUBERCULOSIS.  495 

Diagnosis. — Tuberculosis  after  morbilli. 

Family  History. — The  father  died  of  tuberculosis  when  the  infant  was  six 
months  old.  Tlie  mother  is  still  living  and  in  apparent  good  health.  Two  other 
children  in  the  same  family  show  no  evidence  of  illness.  The  family  live  in  a 
rear  house  behind  a  tenement  house.  The  weight  of  the  child  when  first  seen  was 
sixteen  pounds. 

Treatment. — An  emulsion  of  the  yolks  of  6  eggs  containing  sugar,  and  15  drops 
of  creosote  carbonate  was  fed  each  day.  Buttermilk  and  the  serum  of  bullock's  blood 
was  given  in  ^vineglassful  doses  several  times  a  day.  The  child  was  sent  to  the 
country  and  ordered  to  live  out  of  doors.  The  appetite  improved  and  the  cough 
lessened.  From  month  to  month  the  clinical  symptoms  gradually  subsided  and 
at  the  end  of  two  years  the  physical  signs  in  the  lungs  entirely  disappeared,  and  her 
weight  increased  to  32  pounds. 

In  this  case  tubercle  bacilli  were  found  in  the  suptum  that  was  vomited  after  a 
severe  coughing  paroxj'sm.     The  case  is  well  to-day. 

Case  II.  A  girl,  12  years  old,  seen  by  me  some  years  ago,  was  brought  to  my 
children's  clinic  at  the  New  York  Post-Graduate  Medical  School  and  Hospital.  She 
was  suffering  with  headache,  cough,  general  malaise,  poor  appetitt*,  and  emaciation. 
She  had  been  under  the  treatment  of  a  physician  who  diagnosed  malaria.  The 
bowels  were  ii'regular,  at  times  constipated,  at  other  times  diarrheal.  The  urine, 
light  amber  color,  contained  nothing  abnomal.  The  child  perspired  freely  at  the 
slightest  exertion,  even  after  each  paroxysm  of  cough. 

Previous  History. — She  was  a  bottle-fed  infant.  Had  measles  and  broncho- 
pneumonia at  3  years.  When  5  years  old  had  had  whooping-cough  which  lasted 
four  months.    Excepting  an  occasional  cough  no  other  symptoms  were  present. 

Family  History. — The  family  history  is  good.  Both  parents  are  living  and 
four  brothers;  all  are  healthy.  The  only  history  as  to  etiology  is  that  this  girl 
has  lived  in  unsanitary  surroundings,  besides  having  a  weakened  state  of  the 
respiratory  tract. 

Physical  Examination. — ^At  the  first  examination  she  appeared  slightly  icteric, 
the  spleen  was  enlarged,  the  liver  normal.  There  was  a  slight  dullness  at  the 
apes  of  the  right  side,  some  mucous  rales  and  harsh  breathing.  There  was  a  slight 
expectoration,  no  history  of  haemoptysis.  Nose  bleeditig  was  complained  of  occa- 
sionally. The  diagnosis  was  made  by  the  presence  of  tubercle  bacilli  in  the 
sputum.  Each  month  her  sputum  was  examined,  and  it  was  found  that  the 
sputum  which  was  expectorated  during  the  early  morning  hours,  between  4  and  6 
A.M.,  contained  the  greatest  number  of  tubercle  bacilli.  After  four  months  of  treat- 
ment it  was  found  that  the  bacilli  in  the  morning  sputum  were  so  sparingly  present 
that  evidently  some  change  was  going  on.  The  symptoms  of  headache  and  malaise 
disappeared  entirely.  The  icteric  condition  disappeared.  The  epistaxis  has  not 
shoMTi  itself  within  the  last  five  months.  A  careful  examination  of  the  sputum 
four  times  a  month  has  not  shown  a  single  tubercle  bacillus. 

The  treatment  consisted  in  remo\ing  the  child  from  school  and  giving  her  a 
substantial  diet  of  which  proteins  formed  the  chief  part.  The  hygienic  conditions 
were  improved  as  much  as  the  circumstances  of  the  family  would  permit. 

I  impressed  the  family  with  the  necessity  of  removing  the  child  to  the  country 
and  she  was  given  into  the  employ  of  a  farmer,  and  ordered  to  be  in  the  open  air 
all  of  the  time.  Six  months  later  I  saw  the  case  again.  She  had  gained  in  weight. 
Her  cough  had  ceased  and  the  physical  signs  were  lessened. 

The  child  lived  in  the  country  eighteen  months. 


496  THE  INFECTIOUS  DISEASES. 

At  the  end  of  this  time  there  was  no  evidence  of  cough  nor  of  the  general 
malaise  excepting  the  physical  signs  on  auscultation  and  percussion.  I  haA^e  seen 
this  child  in  all  about  seven  years  and  believe  that  she  is  quite  healthy.  The 
pulmonary  symptoms  have  entirely  disappeared. 

According  to  Loomis,  tuberculosis  and  cavities  in  the  lungs  can  and  do  heal. 
I  have  good  reason  to  believe  that  in  this  patient,  in  whom  we  diagnosed  apex  tuber- 
culosis or  a  catarjhal  tuberculosis  affecting  the  apices  of  both  lungs,  this  process 
was  arrested  in  its  incipiency. 

Diag'nosis. — Method  of  Obtaining'  Sputum:  In  infants  and  5^oiTng-  chil- 
dren who  do  not  expectorate,  the  following-  method  of  obtaining  sputum  is 
suggested  b}^  Findlaj^  of  Glasgow :  ''With  a  piece  of  gauze  on  the  fore- 
finger, the  pharynx,  and  especially  the  epiglottis,  is  irritated  so  as  to  induce 
coughing,  and  any  expectoration  that  is  coughed  up  is  swept  out  of  the 
mouth  l_^efore  it  has  time  to  be  swallowed.  The  quantity  thus  obtained 
varies,  but  as  a  rule  is  sufficient  for  bacteriological  examination." 

The  diagnosis  Avill  frequently  be  very  difficult,  especially  so  if  no  data 
can  be  obtained  which  will  complete  our  clinical  picture.  If  the  child 
has  been  exposed  to  tuberculous  individuals  then  a  suspicion  may  arise  (if 
there  is  a  tuberculous  family  disposition)  of  a  possibility  of  the  development 
of  this  disease.  Frequently  the  symptoms  are  such  as  to  resemble  tj^phoid, 
but  if  there  is  an  absence  of  roseola,  if  the  diazo  reaction  is  absent, 
and  if  the  Widal  reaction  is  absent,  then  miliary  tuberculosis  must  be 
inferred.  The  ophthalmoscopic  examination  must  not  be  looked  upon  as  a 
positive  criterion,  for  miliary  tuberculosis  may  exist  in  spite  of  the  absence 
of  tuberculosis  of  the  choroid.  For  differential  diagnosis  between  tubercu- 
losis and  syphilis,  see  chapter  on  "Syphilis." 

Tuberculides. 

Papulo-necrotic  tuberculides  are  round,  flat  papules,  brownish  in  color. 
They  have  a  central  whitish  depression  and  are  usually  covered  with  a  small 
scale.  They  may  occur  on  any  part  of  the  body.  Their  most  frequent  loca- 
tion is  on  the  forearm,  thighs,  the  external  surfaces  of  the  legs,  and  be- 
tween the  thighs.    They  sometimes  occur  on  the  face. 

With  the  presence  of  the  papulo-necrotic  tuberculides  aided  by  a  von 
Pirquet  skin  reaction  we  have  one  of  the  best  means  at  our  command  of 
confirming  the  diagnosis  of  infantile  tuberculosis.  Even  though  the  von 
Pirquet  reaction  is  negative,  the  presence  of  tlie  papulo-necrotic  tuber- 
culides strongly  favors  a  diagnosis  of  tuberculosis. 

TIallopeau  in  1896  at  the  Third  International  Dermatological  Congress 
brought  out  the  value  of  this  lesion. 

Tuberculin  Eeaction  an  Aid  to  the  Diagnosis  of  Latent 
Forms  of  Tuberculosis.^ 

Von  Pirquet  found  that  by  inoculating  the  skin  with  a  minute  quantity 
of  old  tuberculin  a  local  inflammatory  reaction  is  produced.     There  is  no 

^  Complete  literature  and  details  published  in  the  New  York  Medical  Journal, 
October  19,  1907. 


PLATE   XVIIL 


Papulo-necrotic  Tuberculides  in  a  r-liild  two  years  old,  seen  dnring  my 
service  at  the  Willard  Parker  Hospital.  A  valuable  diagnostic  lesion  of 
tlie  skin.      (Original.) 


TUBERCULOSIS.  497 

fever  nor  general  systemic  disturbance  after  such  inoculation.  With  the 
older  method  of  Koch  fever  follovi^ed  each  injection.  The  technique  is  as 
follows:  Wash  the  arm  with  ether  and  scarify  three  small  areas,  but  not 
enough  to  produce  a  bloody  surface.  Into  two  of  the  scaj-ified  areas  inocu- 
late (similar  to  vaccination)  diluted  tuberculin  of  the  strength  of  one  part 
tuberculin  with  three  parts  normal  saline  solution.  Leave  the  third  scari- 
fied area  without  inoculation  as  a  control.  After  twenty-four,  rarely  later 
than  forty-eight,  hours  a  local  inflammatory  reaction,  about  10  millimeters 
in  width,  surrounding  the  inoculated  area,  denotes  a  positive  reaction.  In 
the  last  stages  of  miliary  tuberculosis  and  tuberculous  meningitis  no  reaction 
follows.    The  ophthalmo  reaction^  is  another  method  of  diagnosis. 

Prog-nosis. — The  success  attained  during  the  last  few  years-  in  the 
treatment  of  tuberculosis  proves  the  scientific  progress  made.  Several  years 
ago  this  disease  was  considered  hopeless. 

Modem  physicians  recognize  the  importance  of  treating  the  collapsed 
lung  that  has  become  so  through  unsanitai-y  surroundings,  in  the  light  of 
cause  and  effect.  The  prognosis  therefore  will  depend  on  the  age  of  the 
patient,  the  stage  of  the  disease  in  which  treatment  is  commenced,  and  the 
v/ill  power  of  the  patient.  The  vitality  of  children  and  their  ability  to  pass 
tiirough  long  periods  of  illness  and  finally  recover  should  be  remembered 
when  the  outcome  of  the  case  is  considered.  Severe  forms  of  marasmus, 
with  marked  emaciation,  apparently  hopeless,  finally  recovered.  I  have  also 
seen  severe  forms  of  apex  tuberculosis  in  children  that  entirely  recovered 
after  proper  hygienic  and  dietetic  treatment  was  instituted. 

It  is  our  duty  to  instruct  parents  and  those  in  charge  of  children  of  the 
dangers,  on  the  one  hand,  where  treatment  is  neglected,  and  to  picture  to 
them,  on  the  other  hand,  how  successful  other  cases  have  been  when  the  dis- 
ease was  properly  handled. 

Treatment. — Dietetic  Treatment:  Next  to  sunshine,  fresh  air,  and 
pulmonary  gymnastics  comes  nutrition.  A  child  that  is  properly  strength- 
ened with  milk,  buttermilk,  cocoa,  eggs,  cereals,  cheese,  green  vegetables, 
fruits,  meats,  and  meat  broths  will  certainly  be  better  able  to  recover  tlian 
one  that  is  underfed. 

One  Point  Concerning  Feeding. — Milk  if  given  should  not  be  repeated 
oftener  than  once  in  four  hours.  The  yolk  of  a  fresh  egg  may  be  added 
just  before  feeding.  When  soup  is  given  the  yolk  of  a  fresh  egg  may  be 
added  to  it.  I  frequently  give  the  yolks  of  eight  or  ten  eggs  in  twenty-four 
hours  if  the  gastric  condition  warrants  the  same.  Strict  attention  must  be 
paid  to  the  bowels  so  that  we  do  not  overfeed  and  produce  a  dyspepsia  by 
overfeeding.    If  milk  is  not  well  borne  it  may  be  peptonized. 

^  Calmette  advises  iising  a  Vioo  per  cent,  dilution  of  tuberculin  dropped  into 
the  eye. 

-  "Tuberculosis  and  How  to  Combat  It,"  prize  essay  by  S.  A.  Knopf,  is  well 
worth  reading. 

82 


498  THE  INFECTIOUS  DISEASES. 

General  Treatment. — In  the  treatment  of  tuberculosis  the  most  im- 
portant point  to  remember  is  that  fresh  air  is  the  best  lung  disinfectant 
that  we  possess.  No  remedy  will  kill  tubercle  bacilli  as  quickly  as  sunshine 
and  fresh  air.  This  should  be  impressed  on  every  family  wherein  a  case 
of  tuberculosis  is  found.  The  progress  made  in  recent  years  by  climatic 
treatment  has  demonstrated  the  fact  that  cavities  in  the  lung  will  frequently 
heal  under  proper  treatment.  The  open-air  treatment  has  gained  such  a 
strong  foothold  that  we  do  not  encounter  the  same  difficulties  that  we  did 
years  ago  when  recommending  open  windows  night  and  day.  The  great 
bugbear  of  night  air  should  be  removed,  because  fresh  air  at  night  is  equally 
as  important  as  it  is  by  day. 

Heliotherapy. — Exposing  the  body  to  sun  baths  in  addition  to  living 
out-of-doors,  preferably  at  an  altitude  of  several  thousand  feet,  are  recognized 
as  the  strongest  modem  therapeutic  measures  employed.  Statistics  show 
the  great  advantage  of  heliotherapy  in  mountainous  regions;  on  the  other 
hand,  we  have  excellent  results  at  the  sea  level  in  tubercu.lous  children.^ 

Pulmonary  Gymnastics. — Deep  inspiration  and  expiration  will  oxy- 
genate the  lungs  when  regularly  performed. 

Deep  breaths  taken  in  the  mountains  on  which  there  are  pine-needle 
trees  will  do  more  toward  expanding  and  imp'egnating  diseased  or  collapsed 
portions  of  the  lung  than  will  the  inhalation  of  a  hundred  times  that  quan- 
tity of  pine-needle  oil  in  the  close,  stuffy  room  when  diffused  from  an  atom- 
izer. The  hygienic  treatment  must  not  be  confined  to  walking  and  breath- 
ing the  pure  air,  but  must  be  aided  by  tepid  bathing  and  by  stimulating  the 
circulation  of  the  blood  by  friction  with  a  coarse  Turkish  towel.  Sea  salt 
can  be  added  to  the  bath.  When  the  feet  or  hands  are  cold  they  should  be 
briskly  rubbed  until  the  blood  circulates  freely. 

Medicinal  Treatment. — Codliver-oil  internally  should  be  tried.  If  it 
is  not  well  borne  it  can  be  used  by  external  friction  over  the  whole  body, 
daily  for  ten  or  fifteen  minutes.  This  is  the  so-called  codliver-oil  bath. 
If  codliver-oil  is  not  tolerated,  butter  should  be  given  in  large  quantities. 
Codeine  in  ^/iq-  to  V4-  grain  doses  can  be  given,  or  heroin  in  ^/go-  to  ^/ss- 
grain  doses,  three  times  a  day,  may  be  given  to  relieve  cough.  For  the 
relief  of  the  night  sweats  sulphate  of  atropine,  ^/ijo  to  ^Aoo  ol  a  grain, 
three  times  a  day,  should  be  given.  Toxic  symptoms  should  always  be 
looked  for  in  the  pupils  when  administering  these  drugs.  A  laxative  dose 
of  citrate  of  magnesia  or  calcined  magnesia,  5  to  10  grains,  several  times  a 
day,  is  useful. 

If  blood  is  expectorated,  then  5  to  15  drops  of  fluidextract  of  ergot 
can  be  given  every  few  hours.  In  other  cases  5  to  10  grains  of  powdered 
alum,  repeated  every  few  hours,  may  do  good.    I  have  also  seen  good  results 


^  See  report  of  Dr.   John   Winters   Brannan  on  Results  with  Heliotherapy  at 
the  Seaside  Hospital,  Coney  Island,  1913. 


PLATK   XIX 


Old  Tuberculin, 
Undiluted 


Dilution — 1  :  4 


Dilution— 1  :  16 

Dilution— 1  :  64 

Control,  Not 
Inoculated 


Cutaneous  Reaction  Sliowing  the  Various  Results  with  Concentrated  and 
Diluted  Tuberculin.  Taken  48  hours  after  iudculatiou  by  Dr.  H.muing,  at  the 
clinic  of  Escherich. 


PLATE  XX 


Severe  Cutaneous  Reaction.     Note  the  two  places  inoculated.     The  center 
is  the  control.     (Escherich's  clinic.) 


Scrofulous  Reaction .     Two  outer  places  inoculated.     The 
center  is  the  control.     (Escherich's  clinic.) 


TUBERCULOSIS.  499 

from  5-  and  10-  grain  doses  of  gallic  acid.  Fluidextract  of  hydrastis  cana- 
densis, 3  to  10  drops,  several  times  a  day,  or  hydrastinine  hydroclilorate, 
Vioo  grain,  three  times  a  day,  may  be  tried. 

Tincture  of  iron,  in  5-  to  10-  drop  doses,  is  a  good  hemostatic;  besides 
it  is  a  valuable  tonic.  Stimulation  is  sometimes  required.  Gymnastics  and 
exercise  should  be  ordered.  These  must,  however,  be  supervised,  so  that 
fatigue  is  avoided.  Besides  stimulating  the  circulation,  exercise  aids  in  the 
metabolism  of  food. 

We  must  not  consider  a  case  cured  when  all  active  symptoms  subside, 
but  must  persist  with  climatic  treatment  for  many  years,  to  avoid  a 
reinfection. 

Attention  should  be  directed  to  the  upper  air  passages  and  adenoids 
and  tonsils  removed  if  the  slightest  evidence  of  symptoms  is  noted. 

To  prevent  the  recurrence  of  tuberculous  infection  we  must  remove 
the  patient  from  his  former  surroundings  and  keep  him  away  from  therd 
after  improvement  is  noted.  There  is  danger  of  reinfection  in  taking  a  child 
from  an  out-door  life  of  sunshine  and  fresh  air  back  to  an  unsanitary 
home.  We  should  impress  the  family  with  the  importance  of  continuing 
thorough  oxygenation  of  the  lungs  night  as  well  as  day,  and  keeping  the 
skin  healthy  by  frequent  tub  baths.  Out-door  exercise  should  be  advised, 
both  for  its  stimulating  effect  on  the  circulation,  as  well  as  for  its  value 
in  aiding  food  metabolism. 

Tuberculin. — The  use  of  injections  of  tuberculin  for  diagnostic  as  well 
as  therapeutic  results  dates  back  to  1891,  when  Koch  first  announced  clin- 
ical results.  My  experience  with  tuberculin  at  that  time,  through  the 
courtesy  of  George  F.  Shrady,  at  the  St.  Francis  Hospital,  New  York, 
was  not  very  encouraging.  I  have  also  seen  cases  in  which  tuberculin  Avas 
used  through  the  courtesy  of  Prof.  Adolph  Baginsky,  at  the  Berlin  Chil- 
dren's Hospital.  Baginsky  has  never  encouraged  the  use  of  these  injections. 
In  his  sixth  edition  of  "Lehrbuch  der  Kinderkraukheiten,"  1899,  page 
350,  he  says :  "I  do  not  believe  that  the  injection  of  tuberculin,  especially 
in  very  small  children,  is  without  danger.  I  am  aware  that  Kossel,  m 
Berlin,  uses  the  injections  very  extensively  and  without  ill  results."  In 
young  children  a  dose  of  Vnoooo  milligram  should  be  given,  and  two  weeks 
later  followed  by  an  injection  of  ^/osooo  milligram.  The  injections  should 
be  given  in  the  evening,  and  local  as  well  as  constitutional  symptoms  care- 
fully noted.  These  injections  should  be  given  about  once  a  week  and  the 
dose  gradually  increased,  so  that  at  the  end  of  two  months  V5000  milligram 
can  be  injected  without  producing  severe  reaction. 


CHAPTEE  VI. 
DIPHTHEROID. 

This  term  we  owe  priiuaril}^  to  the  French.  It  was  introduced  into  the 
German  literature  by  Professor  Baginsky,  and,  after  him,  by  Escherich. 

This  disease  is  caused  by  an  infection  resulting  from  a  series  of  germs, 
chiefly  streptococci  or  staphylococci.  It  is  a  disease  which  differs  entirely 
from  diphtheria.  It  is  not  a  serious  disease.  There  are  no  Klebs-Loeffler 
bacilli  present.  The  usual  evidences  of  systemic  infection  are  absent.  The 
child  shows  the  clinical  evidences  of  an  infection  in  a  milder  form  than  is 
usually  met  with  in  diphtheria.  The  prognosis  is  good.  The  treatment 
should  be  directed  toward  restoring  the  normal  condition  of  the  body,  and 
hence  the  saccharated  carbonate  of  iron  given  in  5-  to  10-  grain  doses,  three 
or  four  times  a  day,  is  very  useful.  Locally,  an  astringent  antiseptic  gargle, 
consisting  of  equal  parts  of  Dobell's  solution  and  of  warm  water,  to  be  used 
every  hour  for  gargling,  or  a  1  to  5000  bichloride  of  mercury  solution  is 
very  useful.    Normal  salt  solution  is  also  recommended. 

The  nutrition  of  the  body  will  be  the  means  of  restoring  the  functions 
to  their  normal  state.  It  is  important,  therefore,  to  feed  in  regular  inter- 
vals milk,  soup,  broth,  and  eggs,  if  they  can  be  assimilated.  If  the  child 
is  a  bottle  baby  "or  a  nursling  at  the  breast,  then  a  smaller  quantity  of  food 
should  be  given,  and  if  the  same  is  not  taken  by  the  mouth  then  rectal  ali- 
mentation will  be  urgently  called  for.  It  is  wise  to  isolate  each  and  every 
form  of  diphtheroid  affection  and  thus  prevent  the  possibility  of  the  trans- 
mission of  this  infection. 

PsEUDO  OR  False  Diphtheria. 

Under  this  general  title  are  included  all  cases  of  pseudo-membranous 
or  exudative  inflammation  of  the  mucous  membranes  in  which  the  diph- 
theria bacilli  are  absent. 

Since  Loeffler,  in  18S9,  first  described  a  class  of  pseudo-membranous 
inflammations  of  the  throat  in  which  the  diphtheria  bacilli  were  absent 
and  cocci  present,  it  has  been  established  that  a  certain  portion  of  the 
inflammations  of  the  respiratory  mucous  membranes,  which  closely  re- 
semble the  less  characteristic  cases  of  diphtheria,  are  not  due  to  the  diph- 
theria bacilli,  but  to  cocci,  especially  to  streptococci. 

It  has  been  found  that  streptococci  are  commonly  present  in  the  throats 
of  healthy  persons,  or  at  least  in  the  throats  of  persons  living  in  large  cities, 
and  that  other  forms  of  cocci,  especially  the  pneumococci  and  staphylococci, 
are  apt  to  be  associated  with  them. 

These  germs  seem  to  live  in  the  throat  without  creating  any  disturb- 
ance there,  so  long  as  the  mucous  membranes  are  healthy;  but  under  cer- 
(500) 


PSEUDO-DIPHTHERIA.  501 

tain  conditions,  as  when  the  mucous  membrane  has  been  made  vulnerable 
by  exposure  to  cold  or  other  deleterious  influences,  or  by  the  poison  of  scar- 
let fever,  measles,  or  some  other  disease,  the  streptococci,  alone,  or  asso- 
ciated with  other  cocci,  are  able  to  attack  the  mucous  membrane  and  to 
cause  an  inflammation.  This  may  be  of  any  degree  of  intensity,  from  a 
"imple  inflammatory  hypersemia  to  an  inflammation  with  an  extensive 
production  of  pseudo-membrane  or  with  ulceration.  Such  inflammations 
when  associated  with  the  formation  of  pseudo-membrane  are  known  as 
pseudo-diphtheria.  The  exudate  or  pseudo-membrane  in  pseudo-diphtheria 
is  usually  confined  to  the  tonsils,  but  other  parts,  such  as  the  larynx, 
pharynx,  and  nostrils,  may  be  invaded. 

It  has  been  found  that  the  percentage  of  mortality  in  these  cases  is  far 
less  than  in  diphtheria,  and  that  the  disease  is  seldom,  if  ever,  commu- 
nicated to  others. 

The  Proportion  of  Cases  of  Suspected  Diphtheria  which  upon  Exami- 
nation Prove  to  be  True  Diphtheria. — "As  soon  as  careful  investigation 
had  demonstrated  it  was  possible,  with  proper  precautions,  to  separate  by 
bacteriological  examination  the  cases  of  the  true  from  those  of  the  false 
diphtheria,  large  numbers  of  cases  suspected  to  be  diphtheria  were  exam- 
ined bacteriologically.  The  reports  from  hospitals  in  which  all  cases  of 
suspected  diphtheria  were  examined,  are  of  special  interest  as  showing  the 
proportion  of  cases  of  true  to  false  diphtheria.  The  results  from  these  hos- 
pitals are  all  the  more  valuable  because  they  come  from  all  parts  of  the 
various  cities  in  which  the  respective  hospitals  were  located,  and  hence 
f'pecial  local-  conditions  were  not  likely  to  greatly  influence  the  result  ob- 
tained. Thus,  Baginsky,  in  Berlin,  found  the  diphtheria  bacilli  in  120 
out  of  244  suspected  cases;  Martin,  in  Paris,  126  out  of  200;  Park,  in 
New  York,  127  out  of  244;  Janson,  in  Switzerland,  in  63  out  of  100,  and 
Morse,  in  Boston,  in  239  out  of  400.  Thus,  from  20  to  50  per  cent,  of  the 
cases  sent  to  diphtheria  hospitals  did  not  have  diphtheria. 

"If  we  examine  the  reports  of  examinations  made  under  some  special 
conditions,  as  during  an  outbreak  of  some  contagious  disease  in  a  hospital 
for  children,  we  find  the  results  may  differ  in  a  striking  manner. 

"Thus,  in  1889,  Prudden  made  bacteriological  examinations  of  24 
fatal  cases  of  pseudo-membranous  inflammation  of  the  tonsils,  phannx,  and 
Jarynx.  In  none  of  these  were  the  Loeffler  bacilli  found  to  be  present. 
These  cases  occurred  in  two  hospitals  for  children  in  ISTew  York  in  whicH 
both  scarlet  fever  and  measles  were  at  the  time  prevalent.  During  the  past 
year  we  have  examined  the  exudate  from  46  fatal  cases  of  suspected  diph- 
theria occurring  in  these  same  institutions,  and  found  the  bacilli  present  in 
44  of  them." 

If  scarlet  fever  and  measles  (but  not  true  diphtheria)  were  prevailing 
in  an  institution,  it  is  evident  the  bacilli  would  be  absent  from  the  pseudo- 


502  THE  INFECTIOUS  DISEASES. 

membranes  occurring  in  the  throat  as  a  complication  of  these  diseases.  All 
observers  have  found  the  mortality  far  higher  in  those  cases  in  which  the 
diphtheria  bacilli  were  present  than  in  those  in  which  they  were  absent.  In 
true  diphtheria  the  mortality  has  been  found  to  vary  from  £5  to  70  per 
cent.,  while  in  pseudo-diphtheria  it  varies  from  0  per  cent,  to  20  per  cent. 

DiPHTHEEIA. 

Diphtheria  is  an  acute  infectious  disease  caused  by  the  invasion  of  a 
specific  micro-organism  known  as  the  Klebs-LoefSer  bacillus. 

It  is  a  disease  characterized  by  the  presence,  locally,  of  false  mem- 
branes, known  as  pseudo-membranes. 

The  presence  of  pseudo-membrane  is  frequently  caused  by  the  strepto- 
coccus. The  Klebs-Loeffler  and  the  streptococcus  varieties  are  identical  in 
their  clinical  manifestations. 

Etiology. — This  disease  is  most  frequently  met  with  in  children,  al- 
though adults  are  not  exempt  from  it.     It  is  met  with  in  the  newly  born 
(Jacobi).     It  is  most  frequently  seen  between  the  fourth  and  tenth  years. 
Children  are  especially  disposed  to  this  disease  between  the  ages  of  1  and 
5  years.    Baginsky  reports  a  series  of  2711  cases  in  which : — 
84  occurred  during  the  first  year. 
889  between  the  first  and  fourth  year. 
1411  between  the  fourth  and  tenth  year. 
318  between  the  tenth  and  fourteenth  year. 

There  is  no  difference  in  the  sex  regarding  the  predisposition  to 
diphtheria : — 

1311  in  the  above  series  were  boys. 
1400  were  girls. 

Infection  is  spread  primarily  by  contact.  It  can  be  transmitted 
through  dishes,  play  toys,  and  furniture  to  which  the  Ivlebs-Loeffler  bacilli 
adhere.  Infections  have  been  traced  to  water  and  milk  which  contained 
the  diphtheria  bacillus.  We  know  that  the  Klebs-Loeffler  bacilli  adhere 
to  the  walls  and  ceilings  of  rooms.  The  etiology  of  diphtheria  remained 
obscure  until  Loeffler  discovered  the  bacillus  in  1884. 

Kissing  a  child,  sick  or  convalescing  from  diphtheria,  is  a  direct 
method  of  contracting  the  disease. 

UnliedltUy  Throats. — Diseased  tonsils,  or  adenoid  vegetations  in  the 
pharynx,  are  usually  foci  for  the  development  and  propagation  of  the  Klebs- 
Loeffler  bacillus.  This  has  been  repeatedly  verified  by  me  during  many 
years  of  service  at  the  Willard  Parker  and  Eiverside  Hospitals. 

Thus  it  would  appear  wise  to  put  the  throat  in  as  healthy  a  state  as 
possible  in  order  to  guard  against  the  development  of  this  disease. 

False  diphtheria,  in  which  there  is  a  non-virulent  germ  present,  fre- 
quently resembles  diphtheria. 


DIPHTHERIA. 


603 


Hunt's  differential  stain  and  alpo  tlie  Neisser  stain  will  differentiate 
the  non-virulent  from  the  virulent  form  of  germ. 

Table  No.  46. — Diphtheria  Cases  Under  18  Tears,     Willard  Parker  Hospital. 


I 

•a 
a 

ei 

Under  1  Year. 

(N 

O 
rH 

2  to  3  Years. 

M 

a 

(L> 

X 

-)> 

o 

CO 

1 

m 

» 
in 
O 

C3 

111 
X 
o 
o 

OQ 

as 

O 

CO 

1-1 
cd 
<u 
t» 

00 

o 

n 
u 

03 
Ol 

tw 

o 

o 

00 

10  to  12  Years. 

12  to  15  Years. 

2 

a 
tu 
X 

00 

o 

Male 

798 

49 

159 

138 

121 

87 

62 

33 

31 

28 

30 

33 

27 

1910 

Female 

733 

30 

107 

110 

103 

77 

75 

72 

38 

39 

33 

24 

25 

Total 

1531 

79 

266 

248 

224 

164 

137 

105 

69 

67 

63 

57 

52 

Male 

530 

29 

139 

102 

50 

58 

33 

23 

12 

35 

20 

15 

14 

1911 

Female 

760 

62 

158 

90 

104 

109 

62 

42 

20 

30 

25 

30 

28 

Total 

1290 

91 

297 

192 

154 

167 

95 

65 

32 

65 

45 

45 

42 

Table  No.  47. — Per  cent,  of  Mortality  from  Diphtheria  in  Different 
Cities  of  the  United  States. 


Cities. 

Treatment.        i    IS'.io. 

189G. 

1897. 

1898. 

1899. 

1900. 

1901. 

1902. 

Bill  ti  more,  Md. 

1 
Xo  antitoxin  .  1      .    . 

19.83 
9.8 

17.52 
9.8 

15.01 
9.8 

14.02 

8.3 

13.37 

iiapltiniore   Md 

With  antitoxin 

6.87 

/ 

Lowell,  Mass. 
Lowell,  Mass. 

No  antito.xin  . 
With  antitoxin 

48.0 
28.0 

56.0 
10.0 

27.0 

y.o 

35  0 
9.0 

39.0 
12.0 

30.0 
4.0 

30.0 
11.0 

26  0 
8.0 

Nerwark,  N.  J. 
Newark,  N.  J. 

No  antitoxin . 
With  antitoxin 

23  0 
13.0 

31.0 
11.0 

19.0 
11.0 

17.5 
10.5 

14.5 

8.77 

14.6 

8.1 

22.7 
6.6 

190 
70 

Koche.ster,  N.Y- 
Eocliester,N.Y. 

No  antitoxin  . 
With  antitoxin 

22.7 
12.24 

21.7 
9.6 

2:19 
9.0 

17.5 
9.7 

18.7 
6.5 

8.9 

8.4 

10.90 
6.D7 

Bacteriology. — In  the  year  1883  bacilli  which  were  very  peculiar 
and  striking  in  appearance  were  shown  by  Klebs  to  be  of  constant  oc- 
currence in  the  pseudo-membranes  from  the  throats  of  those  dying  of 
true  epidemic  diphtheria.  One  year  later  Loeffler  published  the  results 
of  a  very  thorough  and  extensive  series  of  investigations  on  this  subject. 
He  found  the  bacillus  described  by  Klebs  in  most  but  not  all  cases  of 
throat  inflammations  which  had  been  diagnosticated  as  diphtheria.  He 
separated  these  bacilli  from  the  other  bacteria  present  and  obtained  them 
in  pure  culture.  When  he  inoculated  these  bacilli  upon  the  abraded  mucous 
membrane  of  susceptible  animals,  pseudo-membranes  were  produced,  and 
frequently  death  followed.  If  a  certain  amount  of  a  bouillon  culture  was 
injected  subcutaneously  into  guinea  pigs,  death  was  caused  with  charac- 
teristic lesions.    Loeffler's  failure  to  find  the  bacilli  in  every  case  examined 


504  THE  INFECTIOUS  DISEASES. 

is  now  explained  by  the  fact  that  certain  varieties  of  pseudo-membranous 
inflammation  caused  by  the  streptococcus  bacillus,  such  as  occur  especially 
in  scarlet  fever,  were  then  wrongly  considered  to  be  true  diphtheria. 

Welch  in  an  address  on  diphtheria  said :  "All  the  conditions  have  been 
fulfilled  for  diphtheria  which  are  necessary  to  the  most  rigid  proof  of  the 
dependence  of  an  infectious  disease  upon  a  given  micro-organism,  viz. :  the 
constant  presence  of  this  organism  in  the  lesions  of  the  disease,  the  isolation 
of  the  organism  in  pure  culture,  the  reproduction  of  the  disease  by  inocula- 
tion of  pure  cultures,  and  similar  distribution  of  the  organism  in  the 
experimental  and  the  natural  disease.  In  view  of  these  facts  we  must  agree 
with  Prudden  that  we  are  now  justified  in  saying  that  the  name  diphtheria,  or 
at  least  primary  diphtheria,  should  be  applied,  and  exclusively  applied,  to 
that  acute  infectious  disease  usually  associated  with  pseudo-membranous 
affections  of  the  mucous  membrane  which  is  primarily  caused  by  the  bacillus 
diphtherige  of  Loeffler.'^ 

The  germs  cannot  be  found  in  the  blood,  but  usually  in  the 
membranes.  Now  and  then  the  specific  germ  may  not  be  easily  found 
in  the  pseudo-membranes.  When  such  is  the  case,  several  cultures  may  be 
necessary  to  demonstrate  the  presence  of  the  Klebs-Loeffler  bacillus.  This 
bacillus  is  most  easily  found  in  the  older  pseudo-membranes. 

Frequently  we  find  the  streptococcus  or  the  staphylococcus  accom- 
panying the  Klebs-LoefSer  bacillus.  We  are  not  justified  in  pronouncing 
the  visible  pseudo-membrane  diphtheria  unless  we  find  the  Klebs-Loeffler 
bacillus  present. 

When  there  is  a  pseudo-membrane  present  and  the  Klebs-Loeffler  ba- 
cillus cannot  be  found,  then  a  provisional  diagnosis  of  diphtheria  can  be 
made. 

Technical  errors  will  sometimes  occur  in  the  taking  of  cultures  or  in 
inoculating  culture  media.  Thus,  the  germ  may  not  be  found.  The  rule 
always  followed  by  the  writer  is  to  isolate  every  patient  having  visible  mem- 
branes until  the  same  have  disappeared. 

The  bacillus  can  frequently  be  transmitted  through  animals.  Cows, 
cats,  dogs,  and  pigeons  having  diphtheria  can  easily  infect  those  coming 
into  contact  with  them.  Cows'  milk  can  transmit  the  disease  if  the  Klebs- 
Loeffler  bacillus  exists  therein. 

Characteristics  of  the  Loeffter  Bacillus. — The  diameter  of  the  bacilli 
varies  from  0.3  to  0.8  micro-millimeters,  and  the  length  from  1.5  to  6.5 
micro-millimeters.  They  occur  singly  and  in  pairs,  and  very  infrequently 
in  chains  of  three  or  four.  The  rods  are  straight  or  slightly  curved,  and 
usually  are  not  uniformly  cylindrical  throughout  their  entire  length,  but 
are  swollen  at  the  ends,  or  pointed  at  the  ends  and  swollen  in  the  middle 
portion.  Even  from  the  same  culture  different  bacilli  vary  greatly  in  their 
shape  and  size.    The  two  bacilli  of  a  pair  may  lie  with  their  long  diameter 


DIPHTHERIA.  505 

in  the  same  axis,  or  at  an  obtuse  or  an  acute  angle.  The  bacilli  possess 
no  spores,  but  have  in  them  highly  refractile  bodies.  They  stain  readily 
with  the  ordinary  aniline  dyes  and  retain  their  color  after  staining  by 
Gram's  method.  With  an  alkaline  solution  of  methylene  blue,  the  bacilli, 
from  blood  serum  especially,  and  from  other  media  less  constantly,  stain  in 
an  irregular  and  extremely  characteristic  way,  namely,  club-shaped. 

The  bacilli  do  not  stain  uniformly.  Certain  oval  bodies  situate  in 
the  ends,  or  in  the  central  portions,  stain  much  more  intensely  than  the  rest 
of  the  bacillus.  Sometimes  these  highly  stained  bodies  are  thicker  than  the 
rest  of  the  bacillus ;  again,  they  are  thinner  and  surrounded  by  a  more  slightly 
stained  portion.  The  bacilli  seem  to  stain  in  this  peculiar  way  at  a  certain 
period  in  their  growth,  so  that  only  a  portion  of  the  organisms  taken  from 


Fig.    157. — Diphtheria  or  Klebs-Loeflfler  bacilli;   smear  preparation  from  ton- 
sillar deposit.     LoefiQer's  stain.     X  800.     { Lenhartz-Brooks. ) 

a  culture  at  any  one  time  will  show  the  characteristic  staining.  In  old 
cultures  it  is  often  difficult  to  stain  the  bacilli,  and  the  staining,  when  it 
does  occur,  is  frequently  not  at  all  characteristic. 

Growth  on  Blood  Serum. — If  we  examine  the  growth  of  the  diph- 
theria bacillus  in  pure  culture  on  blood  serum,  we  will  find  at  the  end  of 
ten  to  twelve  hours  little  colonies  of  bacilli,  which  appear  as  pearl-gray  or 
whitish-gray,  slightly  raised  points.  The  colonies  when  separated  from  each 
other  may  increase  in  forty-eight  hours,  so  that  the  diameter  may  be  14 
inch.  The  borders  are  usually  somewhat  uneven.  These  colonies,  Iving 
together,  fuse  into  one  mass,  especially  if  the  serum  is  rather  moist.  During 
the  first  twelve  hours,  the  colonies  of  the  diphtheria  bacilli  are  about  equal 
in  size  with  those  of  the  streptococci;  but  after  this  time  the  diphtheria 
colonies  become  larger  than  those  of  the  streptococci,  nearly  equaling  those 
of  the  staphylococci. 


506 


THE  INFECTIOUS  DISEASES. 


The  Relation  Between  the  Length  of  the  Bacillus  and  its  Virulence. — 
Some  investigators  believed  that  the  degree  of  virulence  possessed  by  the 
diphtheria  bacilli  could,  to  a  certain  extent,  be  judged  by  their  length. 


« 

i,. 

--  ;,*J 

Fig.  158. — True  and  False  Diphtheria,  (a)  Diphtheria  bacilli  XlOO; 
(6)  characteristic  diphtheria  bacilli  XIOOO;  (c)  colonies  of  diphtheria 
bacilli  X  124;  {d)  even-stained  short  diphtheria  bacilli  X  1000;  (e)  pseudo- 
diphtheria  bacilli  X  1000;  (f)  streptococci  smeared  directly  upon  cover  glass 
from  throat  exudate  XIOOO.     (After  Park.) 

The  longest  bacilli  were  supposed  to  be  the  most  virulent;  those  of  medium 
length  less  so,  and  the  shortest,  little  if  at  all  virulent.  By  observing 
this  characteristic  it  was  thought  cultures  might  become  helpful  in 
prognosis. 

"The   short   Klebs-Loeffler   bacillus   apparently   produces    a   toxin   of 


DIPHTHERIA.  507 

greater  virulency  than  the  larger  forms,  although  the  local  manifestations 
may  not  be  so  extensive.^ 

"The  long  Klebs-LoefTler  bacillus  and  the  streptococci,  when  found 
alone,  give  rise  to  a  mild  type  of  the  disease. 

"The  streptococcus  is  found  associated  with  Klebs-Loeffler  bacillus  in 
most  severe  cases.  Its  special  significance  is  not  so  clear,  but  it  is  possible 
that  by  causing  a  more  intense  inflammatory  reaction  it  opens  avenues  by 
which  the  toxins  of  the  Klebs-Loeffler  bacillus,  plus  its  own  toxin,  may  find 
more  ready  entrance  into  the  circulation. 

"The  apparent  beneficial  action  of  the  antitoxin  of  the  Klebs-Loeffler 
bacillus  in  cases  where  this  bacillus  is  not  present  may  be  due  to  the  fact  that 
though  the  local  action  of  the  difl'erent  microbes  varies  to  a  considerable  ex- 
tent, the  action  of  their  toxins,  as  is  shown  by  the  similarity  of  the  constitu- 
tional symptoms  produced  by  them,  presents  many  kindred  features.  The 
thought  therefore  arises  that  the  antitoxin  of  one  infection  may  have  an  in- 
hibitory efl'ect  on  the  toxin  of  another." 

Very  careful  notes  have  been  made  on  this  point  in  the  examination  of 
the  bacteria  from  the  original  serum  tubes  in  the  following  1613  cases : — 

Table  No.  48. 


No.  of  Cases. 

Mortality. 

Bacilli  of  average  size  found  in   

1398 

82 
67 

66 

26  per  cent. 

27  per  cent. 
35    per  cent. 

12    per  cent. 

Bacilli   longer   than   average   in    

Bacilli  shorter  than  average  in    

Bacilli     short,    not    characteristic    in    shape    and    evenly 
stained,  of  which  many  were  pseudo-diphtheria  bacilli. 

Number  of  cases  examined   

1613 

"The  results  obtained  from  this  examination  of  1613  cultures,  therefore, 
indicate  that  in  New  York  the  great  majority  of  cases  of  diphtheria  yield  in 
cultures  bacilli  of  medium  size  which  are  characteristic  in  shape  and  man- 
ner of  staining.  In  a  moderate  number  of  cases  the  bacilli  found  are  much 
longer,  and  in  about  an  equal  number  they  are  much  shorter.  Both  the 
clinical  histories  and  the  animal  experiments  show  that  whenever  in  their 
shape  and  in  the  way  in  which  they  take  the  staining  fluid  the  bacilli  are 
characteristic,  no  information  as  to  their  virulence,  either  in  men  or  ani- 
mals, can  be  gathered  from  their  length.  Those  bacilli,  on  the  other  hand, 
which  are  short  and  stain  uniformly  with  methylene  blue  usually  prove  to 
be  of  the  pseudo-diphtheria  type,  and  have  no  virulence  in  animals." 

Pathology. — ^The  pathological  lesions  are  caused  by  the  specific  action 
of  the  Klebs-Loeffler  bacillus  and  the  associated  pathogenic  bacteria.     In 


^N.  J.  Class  (N.  Y.  Medical  Journal,  May  14,  1897). 


508 


THE  INFECTIOUS  DISEASES. 


addition  thereto  the  toxins  generated  by  the  various  micro-organisms  pro- 
duce local  destructive  changes. 

As  a  rule,  the  local  pathological  lesion  is  a  whitish,  yellowish-white, 
or  grayish-white  membrane,  which  is  firmly  adherent.  In  some  instances 
a  distinct  greenish  or  black  color  (gangrenous  type)  is  evident. 

In  a  study  of  the  pathology  of  220  fatal  cases  of  diphtheria  by  Mal- 
lory,  Councilman,  and  Pearce  they  found  two  varieties  of  membrane;  first, 
a  dense,  firm,  elastic  membrane  composed  of  a  reticular  structure  with 
considerable  uniformity  in  the  size  of  the  beams  composing  it.  This  mem- 
brane can  be  stripped  off  in  large  flakes.  Second,  a  more  friable  variety 
composed  of  fibrin  forming  a  reticulum  with  more  irregular  spaces  and 
fibers.  The  fibrin  spaces  contain  leucocytes,  amongst  which  are  found  some 
broken  down  cells  (detritus).  The  epithelium  below  the  membrane  con- 
tains polynuclear  leucocytes  and  lymphocytes. 

The  interval  lesions  of  diphtheria  are  those  resulting  from  degenerative 
changes  affecting  organic  structures.  As  a  rule,  haemorrhages  are  found  in 
addition  to  marked  degeneration.  The  lymph  nodes  are  usually  swollen 
and  contain  small  foci  of  cell-necrosis.  Broncho-pneumonia,  if  present, 
shows  the  usual  lesions  common  to  this  condition.  The  nervous  sj^-stem, 
heart,  spleen,  lungs,  and  liver  show  the  most  destructive  effect  of  the  toxins 
of  diphtheria. 

Table  No.  49. — Two  hundred  ani  nine  cases  of  Diphtheria  studied  hy  Councilman,  Mallory, 

and  Pearce,  of  Boston,  in  1901,  showing  the  percentage  of  cases  in  which 

the  different  bacteria  were  found  hy  culture. 


Heart's  Blood. 

Liver. 

Spleen. 

Kidney?. 

Diphtheria  Bacillus       ,    . 

Streptococcus  ...    

Staphylococcus  Aureus     .    ,    . 
Pneumococcus    .    ,            ... 

6    per  cent 
20          " 
2.5       " 

1.5       " 

20   per  cent. 
30 

4 

2.5     " 

12   per  cent. 
27 

3 

1.5       " 

19    percent. 

28 
8 
5 

The  Blood. — John  S.  Billings,  Jr.,^  says: — 

1.  The  red  corpuscles  of  the  blood  in  diphtheria  undergo  a  diminu- 
tion in  number  in  cases  of  moderate  severity  and  in  severe  cases.  Kegen- 
eration  is  slow. 

2.  The  leucocytes  are  increased  in  numbers  in  all  but  two  classes  of 
cases,  exceptionally  mild  cases  and  exceptionally  severe  ones.  As  a  rule, 
the  amount  of  leucocytosis  is  directly  proportionate  to  the  degree  of  severity 
of  the  case.  The  leucocyte-curve  shows  no  correspondence  to  the  clinical 
course  of  the  disease.  The  number  of  leucocytes  often  remains  higher  than 
normal  for  days  after  all  inflammation  has  disappeared.  The  leucocytosis 
is  similar  in  character  to  that  seen  in  pneumonia  and  scarlet  fever,  the 
increase  of  the  leucocytes  being  in  the  so-called  polynuclear  forms. 


^Annual  Eeport,  Health  Department,  1897. 


DU'JITJIKRIA. 


Fig.  159. — Section  fiom  an  inflamed  uvula  covered  with  a  stratified 
fibrinous  membrane,  from  a  case  of  diplitlieritie  croup  of  the  pharyngeal 
oi-gans  (Miiller's  fluid,  haematoxylin,  eosin).  (a)  Surface  layer  of  coaguliun, 
consisting  of  epithelial  plates  and  fibrin  and  containing  numerous  colonies 
of  cocci;  (h)  second  layer  of  coagulum,  consisting  of  fine-meshed  fibrin  net- 
work enclosing  leucocytes ;  (c)  third  layer  of  coaguliun,  lying  upon  the  con- 
nective tissue,  and  consisting  of  a  wide  meshed  reticulum  of  fibrin  enclosing 
leucocytes;  (d)  connective  tissue  infiltrated  with  cells;  (e)  infiltrated  bound- 
ary layer  of  the  connective  tissue  of  the  mucous  membrane;  (f)  heaps  of  red 
blood-cells;  (g)  widely  dilated  blood-vessels;  (li)  dilated  lymph-vesse-ls  filled 
with  fluid,  fibrin,  and  leucocytes;  (i)  duct  of  a  mucous  gland  distended  with 
secretion;  Ck)  transverse  section  of  a  gland;  (1 )  fibrin  reticulum  in  the  super- 
ficial layer  of  connective  tissue.    X45.     (Ziegler.) 


510  THE  INFECTIOUS  DISEASES. 

3.  The  percentage  of  haemoglobin  falls  coincidently  with  the  number 
of  the  red  blood-corpuscles,  and  to  the  same  relative  degree.  But  the 
regeneration  of  the  hsemogiobin  takes  place  much  more  slowly  than  that 
of  the  red  blood-corpuscles. 

■f.  In  cases  treated  with  antitoxin  the  diminution  in  the  number  of 
the  red  corpuscles  is  much  less  marked  than  in  those  cases  treated  without 
it;^  in  a  majority  of  cases  no  such  diminution  takes  place.  The  leucocytes 
are  apparently  unaffected  hj  the  antitoxin.  The  hgemoglobin  is  also  much 
less  affected  in  the  cases  treated  with  antitoxin,  thus  confirming  the  state- 
ment as  to  the  red  corpuscles. 

0.  In  healthy  individuals  injected  with  antitoxin,  the  red  corpuscles 
show  a  very  moderate  reduction  in  number  in  about  one-half  the  cases. 
The  hgemoglobin  is  correspondingly  affected.  The  leucocytes  are  apparently 
unaffected  by  the  injections. 

6.  ISTo  peculiar  characteristic  changes  in  the  naorphology  of  the  cor- 
puscles were  to  be  made  out. 

7.  It  is  improbable  that  any  information  of  prognostic  importance  is 
to  be  gained  by  the  examination  of  blood  in  diphtheria. 

8.  The  antitoxin  treatment  of  diphtheria  has  no  deleterious  effects 
upon  the  blood-corpuscles.  On  the  contrary,  it  seems  to  prevent  degenera- 
tive changes  which  would  otherwise  l^e  brought  about. 

The  Effect  of  Diphtheria  Toxin  on  the  Nervous  System. — E.  Luisada 
and  D.  Pacchioni^  report  the  results  of  a  number  of  exjjeriments  with  diph- 
theria toxin  on  dogs  : — 

1.  The  diphtheria  toxins  applied  directly  to  the  nervous  system  pro- 
voke a  profound  lesion  at  the  point  of  application,  characterized  by  an 
inflammatory  and  degenerative  action. 

2.  These  lesions  are  propagated  more  or  less  extensively  from  the 
point  of  application. 

3.  In  non-immunized  dogs,  which  had  been  injected  with  a  dose  suffi- 
ciently toxic,  the  phenomena  of  local  reaction  were  noted. 

4.  In  immunized  dogs  the  toxins  constantly  produced  alterations  in 
the  central  nervous  system,  intense,  localized,  but  of  less  extent  than  those 
produced  in  dogs  non-immunized. 

5.  The  toxin  applied  directly  to  the  medulla  is  propagated  rapidly  in 
all  directions,  preferring  the  posterior  columns,  the  gray  matter,  and  the 
central  canal,  as  routes.  In  consequence  of  the  bulbar  invasion  death 
occurred  in  the  animals  more  rapidly  when  the  toxins  were  introduced  into 
the  medulla  than  when  applied  to  any  other  portion  of  the  cerebro-spinal 
axis.  When  the  toxins  were  introduced  into  the  cerebral  cortex,  character- 
istic lesions  of  these  regions  were  manifested.  Death  occurred  later  through 
propagation  of  the  j^oison  to  the  medulla. 

^  Giomale  della  R.  Accademia  di  Medicina  di  Torino^  a'oI.  Ixi. 


DIPHTHERIA.  r,-[i 

6.  Toxins  introduced  into  the  sheath  of  tlie  sciatic  nerve  provoked  an 
inflammatory  process  more  or  less  intense,  but  more  circumscribed  than  in 
the  central  nervous  system.  From  the  nerves  the  poison  ascended  to  the 
medulla,  chiefly  through  the  posterior  columns,  and  thus  provoked  an  as- 
cending myelitis. 

7.  The  lesions  produced  upon  the  neuroglia  by  direct  action  of  the  toxins 
are  similar  to  those  reported  by  Vassale,  Donaggio,  and  others  in  the  various 
intoxications  and  infective  processes.  In  the  oblongata  the  prevalent  alter- 
ations are  found  in  the  crossed  pyramidal  tracts  and  posterior  columns. 

8.  The  alterations  produced  by  the  toxins  affect  the  nerve  fibers  more 
than  any  other  part  of  the  nervous  tissue.  These  lesions  affect  principally 
the  myelin,  and  consist  of  a  physical  modification  of  it,  vi'hereby  the  con- 
nections between  the  various  nerves  are  lost.  There  is  partially  a  chemical 
modification  of  the  myelin  also  present. 

9.  The  local  action  of  the  toxins  has  much  importance  in  the  genesis 
of  various  paralyses  as  seen  in  the  human  family,  attacking  first  the  sheaths 
of  the  nerves,  tlien  the  nerves,  and  later  the  nerve  centers  of  the  medulla. 

Action  of  Diphtheria  Poison  on  the  Heart. — F.  Eolly,  first  as- 
sistant to  the  children's  clinic  at  Heidelberg,  as  the  result  of  a  series  of 
experiments  on  animals  v^'ith  the  diphtheria  toxin,^  concludes  that: — 

1.  The  fall  in  l^lood-pressure  induced  by  the  poison  of  diphtheria  is 
due  to  paralysis  of  the  vasomotor  center,  and  also  to  the  paralysis  of  the 
heart,  which  in  spite  of  artificial  respiration  soon  ceases  to  beat. 

2.  This  action  on  the  heart  is  direct,  and  in  warm-blooded  animals  is 
independent  of  the  nervous  system. 

3.  The  paralysis  of  the  heart  develops  after  a  more  or  less  definite 
latent  period.  Direct  injection  of  the  diphtherial  poison  or  transfusion  of 
lethal  diphtherial  blood  interferes  with  the  action  of  the  isolated  normal 
rabbit's  heart  only  after  a  certain  latent  period. 

4.  On  the  other  hand,  the  action  of  the  poison  takes  place  at  the  same 
time,  even  if,  before  the  appearance  of  poisonous  symptoms  or  at  the  be- 
ginning of  such  toxic  action,  the  heart  is  washed  out  with  normal  blood. 

5.  This  property  possessed  by  the  diphtheria  poison  of  action  on  the 
heart  leads  to  the  opinion  that  the  poison  gradually  takes  hold  of  the  heart 
muscles,  and  is  seemingly  stored  up  there  until  its  complete  action  is  mani- 
fest; this  further  explains  the  continuance  of  functional  heart  disturbances 
after  many  of  the  acute  infections. 

Symptoms  and  Course. — Considering  the  clinical  picture  of  this  dis- 
ease, the  following  classification  would  appear  most  plausible: — 

1.  Mild  diphtheria. 

2.  Severe  diphtheria. 

3.  Septic  diphtheria. 

^"Archiv  fiir  exporiiiientelle  Pathologie  xi.  Pharmaknlogie."  42,  1890. 


513  THE  INFECTIOUS  DISEASES. 

Mild  diphtheria  usually  commences  with  symptoms  of  malaise.  The 
appetite  is  poor;  the  tongue  is  coated,  and  the  lymph  glands  at  both  sides 
of  the  jaw  are  swollen.  The  pharynx  is  reddened.  The  mucous  membrane 
is  swollen  and  the  tonsils  are  covered  with  small,  grayish-yellow  plaques, 
which  adhere  very  firml}^.  On  attempting  to  remove  a  piece  of  membrane 
a  bleeding  surface  remains.  This  membrane  peels  off  gradually,  but  leaves 
a  red  line  of  demarcation  on  the  tonsils.  A  close  study  of  the  tonsil  will 
show  the  former  size  of  this  pseudo-membrane.  Usually  the  color  of  the 
pharynx  returns  to  normal;  sometimes  it  is  rather  angemic,  and  after  a 
few  days  the  scar  will  show  the  presence  of  the  former  affection.  When, 
however,  this  condition  does  not  resolve  in  a  few  days,  then  there  is  always 
danger  of  a  systemic  infection.  A  small,  apparently  innocent  patch  on 
the  tonsil  or  pharynx  should  be  as  vigorously  treated  as  a  general  septic 
infection.  In  other  words,  the  danger  of  a  small  patch  extending  to  the 
larynx  should  not  be  forgotten.  Other  forms  of  local  affections  are: 
Sometimes  the  lips  or  the  nose,  the  mucous  membrane  of  the  mouth, 
the  tongue,  the  vagina,  and  the  skin  are  the  seat  of  a  diphtheritic  infec- 
tion. Not  infrequently  diphtheria  affects  the  umbilicus.  Such  diphtheritic 
omphalitis  is  exceedingly  dangerous  and  frequently  fatal.  Ehinitis,  espe- 
cially in  young  infants,  is  frequently  a  diphtheritic  process,  although  re- 
sembling an  ordinary  "cold  in  the  head."  The  sudden  appearance  of  croup 
will  frequently  cause  a  fatal  termination  if  neglected. 

Severe  Diphtheria. — This  condition  usually  commences  with  fever. 
The  temperature  varies  between  101°  and  102°  F.  If  children  are  old 
enough  they  will  complain  of  chills.  It  is  not  uncommon  to  have  con- 
vidsions.  The  cheeks  are  usually  flushed;  in  some  instances  they  are  very 
pale.  The  mucous  membrane  of  the  mouth  is  reddened.  The  pharynx  has 
a  dark-red  color.  The  tonsils  are  swollen.  Both  tonsils  are  intensely 
congested  and  covered  with  a  yellowish  or  yellowish-gray  membrane.  The 
uvula  is  usually  involved.  There  is  pain  on  swallowing  and  a  decided  nasal 
tone  of  voice.  The  submaxillary  glands  are  swollen.  The  nose  discharges 
an  acrid  fluid  containing  yellowish  shreds  or  flakes.  In  many  cases  after 
careful  treatment  the  appetite  returns.  The  diphtheritic  patches  are 
limited  in  area.  The  intense  swelling  and  congestion  fades.  The  mucous 
membrane  appears  and  the  swelling  of  the  submaxillary  glands  subsides,  so 
that  conditions  resume  their  normal  state.  On  the  other  hand,  the  affection 
may  spread  from  the  pharj-nx  and  involve  the  velum  palatinum  and  extend 
downward  so  that  the  larynx  is  involved,  causing  stenosis  and  other  serious 
symptoms. 

Septic  Diphtheria. — In  this  type  of  diphtheria  the  resemblance  to  a 
typhoidal  condition  associated  with  profound  toxaemia  is  noted.  In  septic 
diphtheria  the  general  manifestations  resemble  a  severe  form  of  typhoid. 
The  tongue  is  shining  and  dry.     The  submaxillary  glands  are  very  much 


DIPHTHERIA. 


513 


swollen.  The  children  appear  puffed,  and  the  face  has  a  pale,  waxy  appear- 
ance. The  extremities  are  cool.  The  heart  sounds  are  weak,  sometimes 
inaudihle.  The  pulse  is  small,  sometimes  thready,  and  can  be  counted  with 
difficulty.  There  is  severe  constipation,  rarely  diarrhoea.  The  brain  is  clear, 
although  the  children  appear  in  a  semi-comatose  condition,  moaning  and 
with  mouth  open.  The  urine  is  diminished  and  contains  albumin  and  also 
epithelium.  There  is  a  general  apathetic  condition,  with  cardiac  weakness. 
In  other  instances  there  is  a  decided  htemorrhagic  tendency.  HaBmorrhagic 
spots  appear  on  the  skin.    The  urine  is  bloody.    The  stools  contain  blood. 


i9a>3- 

DATES  OF  OBSERVATIONS                                     | 

^Q.]?\.. 

6 

7 

8 

9 

10 

11 

12 

13 

Cent!  Tahr. 

AM>M 

am:pm 

AMiPM 

am:pm 

am:pm 

am;pm[am;pm 

am'pm 

39°  ~ 
38"" 

•8 
•( 

-102°-* 

i?, 

•  s 

•6 

S"*"* 

^•N 

.^ 
f^ 

-m-2 

:/ 

f: 

\ 

37  ~ 

•S 
•6 

'99° • * 

■  S 
•  6 

:  V 

k/ 

\, 

.i 

■  1  •• 

1     ■ 

36  ~ 

m  ■■■: 

■    i 

■  s 
•0 

97°- 2 

•  8 

•  6 
0  ■  1 

96   -2 

^5 

32 

Puhe 
per  minute 

^•^ 

3c5 

1^ 

§1 

licspiratityAS 
per  minute 

^ 

g5 

Fig.  160. — Septic  Type  of  Diphtheria  Complicated  by  Myocarditis. 
The  effect  of  the  poison  is  shown  on  the  heart.  Note  the  pulse-rate,  low- 
temperature  and  the  rspiration.     (Original.) 


Expistaxis  is  frequent.  There  is  a  general  somnolence.  A  tendency  to 
collapse,  ending  fatally. 

The  diagnosis  depends  on  the  presence  of  a  membranous  exudate  cover- 
ing the  tonsils  and  pharynx.  This  type  of  disease  is  usually  associated 
with  nasal  diphtheria.  There  is  a  foul-smelling  discharge,  .sometimes  a 
marked  gangrenous  odor,  from  both  nose  and  mouth.  When  the  membrane 
exfoliates  it  is  not  uncommon  to  have  severe  epistaxis.  The  temperature 
ranges  between  100°  and  101°;  at  times  subnormal  temperatures  are 
encountered.    There  is  a  tendency  to  collapse. 

Nasal  Diphtheria. — The  nasal  infection  may  be  an  extension  from  the 
pharynx  upward,  or  the  disease  may  be  confined  to  the  nose  and  localized 
there.    Vigorous  treatment  should  be  installed  early  in  the  disease.     Owing 

33 


514 


THE  INFECTIOUS  DISEASES. 


to  the  large  amount  of  l}anphoid  tissue  in  the  naso-pharynx,  the  tendency 
to  profound  toxaemia  from  absorption  should  be  remembered,  and  the 
toxin  inhibited  by  early  and  active  treatment. 

When  there  is  a  general  infection,  then  greater  attention  should  be 
paid  to  the  condition  of  the  heart.  The. pulse  is  usually  small  and  thready. 
The  heart  sounds  are  feeble;  sometimes  they  are  muffled.  In  other  in- 
stances there  is  a  tachycardia.    The  extremities  are  usually  cold.    If  these 


Oct. 

15 

16 

17 

18 

19 

20 

21 

'  22 

Fahr. 

AM.    PM. 

AM.    PM. 

AM.    PM. 

AM.    PM. 

AM.    PM. 

AM.    PM. 

AM.    PM. 

AM.    PM. 

8 

.     » 

.  S*  c^ 

"104°  2 

.'.''S 

.       ;2 

e 

.>^ 

~I03°  - 

•"^ 

■?l5S 

.  \ 

.■^ 

■  \ 

■fi 

4 

■  \ 

:-^ 

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8 

^   -A 

|-           '' 

\  /  \ 

-           4 

\/ 

-101°  2 

V- 

8 

• 

■  A 

-           6 

7  \ 

-100°  2 

\    1 

,        - 

-           8 

\  / 

\      • 

-           4 

v.! 

"99°  - 

\r 

•~^ 

8 

\ 

-          6 

N  •  , 

y'^ 

V    •    . 

-9S°   2 

Pulse 

c^ 

trv 

oo 

^ 

^.^ 

c> 

^l 

<=> 

xn 

Xier 

Si 

L; 

Si 

s, 

^^ 

villi. 

Resp. 
per 

il 

ej 

§ 

§ 

§ 

,§ 

§ 

03 

g 

oo 

^ 

00 

CO 

■nan. 

tS 

Ozs. 

qs. 

qs. 

qs. 

qs. 

qs. 

qs. 

qs. 

qs. 

Dcfcc 

1 

11 

1 

1 

1 

1 

1 

1 

Fig.  161. — Case  of  Nasal  Diphtheria.  George  P.  Willard  Parker 
Hospital.  Injected  with  3000  units  of  antitoxin  on  the  15th,  and  5000  on 
the  17th.     (Original.) 


symptoms  do  not  subside,  and  the  affection  spreads,  then  there  may  be  later 
a  total  absence  of  the  patellar  reflexes.  There  may  also  be  vomiting,  a 
decided  apathetic  condition,  and  a  slowing  of  the  heart's  action  (brady- 
cardia) . 

George  P.,  aged  TVo  years,  admitted  to  the  Willard  Parker  Hospital  Oct.  15th; 
ill  two  days.  General  condition,  fair.  No  pseudo-membrane  was  visible  in  the 
throat.  The  cervical  glands  were  very  much  enlarged.  There  was  a  serosanguineous 
discharge  from  the  nose;  besides,  the  entrance  to  the  nostrils  appeared  angry  and 
excoriated.  Bacteriological  examination  showed  Klebs-Loeffler  bacilli.  Patient  was 
allowed  out  of  bed  October  22d. 


PLATE  XXI 

Case  A. — Common  Type  of  Diphtheria.  Child  three  years  old.  Seen 
on  fourth  day  of  illness  at  the  VVillard  Parker  Hospital.  Exudate  covering 
tonsils,  pharynx,  and  uvula.  Received  in  all  16,000  units  of  antitoxin. 
Throat  clear  on  sixth  day.     Case  discharged  cured.      (Original.) 


Case  B. — Follicular  Type  of  Diphtheria.  Child  seven  years  old. 
Seen  on  second  day  of  illness  at  the  Willard  Parker  Hospital.  The  mem- 
i)rane  involved  the  lacunae  of  the  tonsils.  Note  the  close  resemblance  to 
follicular  tonsillitis.     Received  in  all  6,000  units  of  antitoxin.      (Original.) 


Case  C. — H.faiorrhagic  Type  of  Diphtheria.  Child  seven  and  one- 
half  years  old.  Seen  on  sixth  day  of  illness  at  the  Willard  Parker  Hospital. 
Tonsillar  and  post- pharyngeal  exudate.  Severe  nasal  and  postpharyngeal 
haemorrhages  during  exfoliation  of  membrane.  Received  in  all  15,000  units 
of  antitoxin.  Throat  clear  on  ninth  day  of  illness.  Myocarditis  developed. 
Case  discharged  cured  four  weeks  after  admission.      (Original.) 


Case  D. — Septic  Type  of  Dipjititeria.  Child  eight  years  old.  Seen 
on  the  fifth  day  of  illness  at  the  \Yil1ard  Parker  Hospital.  The  pseudo- 
membrane  in  this  case  covered  the  hard  palate  and  extended  in  one  large 
mass  down  the  pharynx,  completely  hiding  the  tonsils.      (Original.) 


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PLA  IK  XXI 


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DIPHTHERIA. 


515 


The  liver  is  usually  very  much  enlarged  and  feels  very  hard  on  palpa- 
tion. In  other  cases  there  will  be  marked  diminution  in  the  quantity  of 
urine.  When  urine  is  scanty  and  contains  casts  and  blood,  showing  a  dif- 
fuse nephritis,  then  it  is  not  rare  to  find  convulsions  of  a  ura3mic  character, 
resulting  fatally.  The  sudden  appearance  of  diarrhoea  is  frequently  a  very 
serious  symptom,  resulting  in  collapse  and  ending  fatally. 

In  other  instances  continuous  crying  may  be  the  forerunner  of  earache 
resulting  in  suppuration.  Not  infrequently  moist  rales  and  bronchial 
breathing  show  evidences  of  broncho-pneumonia  areas  in  the  lungs,  so  that 
the  general  infection,  of  a  child  with  diphtheria  should  be  dreaded,  owing  to 


<90i- 

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Fig.  162. — Broncho-pneumonia  Complicating  Diphtheria.  Antitoxin 
rash  scarlatinal  in  character  appeared  four  days  after  injection.  Second 
eruption  appeared  ten  days  later.  Note  peculiarity  of  temperature  curve. 
Severe  croup  required  intubation.  Child  remained  well  for  thirty-two  days 
after  second  intubation,  then  severe  croup  appeared  and  required  intubation. 
In  all,  seven  intubations  were  required.   Child  discharged  cured.     (Original.) 

the  danger  of  complications  associating  themselves  with  the  primary  con- 
dition. 

Follicular  Forms. 

The  crypts  or  follicles  are  frequently  the  seat  of  a  diphtheritic  infec- 
tion. Small,  yellowish-white  or  grayish-white  membranes  visible  as  pin- 
point deposits  will  be  seen.  This  variety  is  frequently  styled  lacunar 
diphtheria. 

Rashes. — Very  frequently  rashes  follow  the  injection  of  antitoxin. 
These  rashes  are  of  an  erythematous  character: — 


516  THE  INFECTIOUS  DISEASES. 

Table  No.  50. — Observations  on  a  Series  of  350  Cases  of  Antitoxin  Rashes  at  the 

Willard  Parker  Hospital.    Site  of  their  First  Appearance,  Day  of  Irwasion 

after  Initial  Dose,  and  Persistence  of  Rashes. 

Erythematous  rashes    109 

Punctiform    19 

Urticarial    223 

Erythematous   rash  on  face    9 

Erythematous  rash  on  buttocks  11 

Erythematous  rash  on  upper  extremities   18 

Erythematous  rash  on  lower  extremities   7 

Erythematous  rash  on  body    64 

Punctiform  rashes  on  body 18 

Punctiform  rashes  on  upper  extremities    1 

Urticarial  rashes  on  face  . ' 18 

Urticarial  rashes  on  buttocks   18 

Urticarial  rashes  on  upper  extremities 41 

Urticarial  rashes  on  lower  extremities   30 

Urticarial  rashes  on  body   128 

Rashes  appearing  on  first  day 6 

Rashes  appearing  on  second  day 39    - 

Hashes   appearing  on  third  day 30 

Rashes   appearing  on  fourth  day    27 

Rashes  appearing  on  fifth  day    34 

Rashes  appearing  on  sixth  day   35 

Rashes  appearing  on  seventh  day    28 

Rashes  appearing  on  eighth   day    25 

Rashes   appearing  on   ninth   day    "■  ■  14 

Rashes   appearing   on   tenth   day 12 

Rashes  appearing  on  eleventh  day 1 

Rashes  appearing  on  twelfth  day 4 

Rashes  appearing  on  thirteenth  day  3 

Rashes  appearing  on  fourteenth   day    2 

Rashes  appearing  on  fifteenth  day   1 

Rashes  appearing  on  sixteenth  day   2 

Rashes  appearing  on  eighteenth  day  1 

Rashes  appearing  on  twentieth   day    1 

Rashes  appearing  on  twenty-first  day   1 

Rashes  appearing  on  twenty-seventh  day   1 

Persistence  of  Antitoxin  Rashes. 

Rashes  lasting  one  day 17 

Rashes  lasting  two   days    174 

Rashes  lasting  thre-?    ^ys    55 

Rashes  lasting  four  c:    , 3 

Flashes   lasting   five   (1;\  -    6 

Rashes   lasting  six  dr..; 2 

Rashes  lasting  eight    :         1 

Rashes   lasting  nine   c.  ^       1 


PLATE  XXII 


Lizzie  F.,  5  years  old,  was  admitted  to  the  Willard  Pavkov  TTospital  in 
September,  1904.  She  was  ill  seven  days  before  admission.  Diphtheria  was 
present  on  both  tonsils.  There  was  slight  glandular  swelling.  The  general 
systemic  condition  was  poor.  The  temperature  was  101°  F.,  pulse  120, 
respiration  24.  The  child  received  5000  units  of  antitoxin  on  admission, 
and  on  the  following  daj^  a  second  injection  of  4000  units.  Four  days  after 
the  second  injection  of  antitoxin,  the  throat  cleared  so  that  ivo  membrane 
was  visible.  Two  days  later,  or  six  days  after  the  second  antitoxin  injec- 
tion, a  universal  rash  appeared  on  the  face,  chest,  abdomen,  back,  and  ex- 
tremities. This  rash  was  morbilliform  in  character  and  persisted  for 
twenty-two  days,  although  it  was  chiefly  confined  to  the  arms  and  legs.  Xo 
complications  followed.  The  child  left  the  hospital  in  excellent  condition. 
(Original.) 


DIPHTHERIA.  517 

C.  Hartung  quotes  a  number  of  European  observers,  who  found  an 
antitoxin  rash  in  11.4  per  cent  of  2661  cases.  Berg  found  that  rash 
in  82  cases  out  of  337,  or  24  per  cent.  This  condition  is  described  in  detail 
in  Nothnagel's  Encyclopcedia,  pages  153-162. 

While  Northrup  reports  147  cases  of  rash  occurring  between  the  seventh 
and  twelfth  day,  other  observers  report  the  rash  as  occurring  much  earlier. 
In  the  series  above  reported  the  largest  number  of  rashes  occurred  on  the 
second  and  third  day  after  the  injection.  I  have  frequently  seen  an  anti- 
toxin rash  several  hours  after  the  injection  was  given,  while  the  majority 
of  rashes  were  fully  developed  on  the  second  day. 

The  following  case  illustrates  the  rapidity  with  which  a  rash  may 
appear : — 

Laurence  S.,  aged  4  years.  Admitted  September  8,  1903,  to  the  Willard 
Parker  Hospital,  on  the  third  day  of  illness.  He  was  in  a  poor  condition  when 
admitted.  He  was  intubated  about  one-half  hour  before  being  admitted  to  the 
hospital.  Slight  retraction  present.  Membranes  on  right  tonsil.  Profuse  nasal 
discharge. 

The  physical  examination  was  negative.  The  heart  regular  and  of  good  force; 
4000  units  of  antitoxin,  of  serum  (horse)  220,  were  given  'when  admitted.  There 
was  no  rash  present  when  the  antitoxin  was  injected.  Seven  minutes  after  the  anti- 
toxin injection  the  patient  had  a  profuse  rash  all  over  the  chest,  extending  from 
the  fifth  ribs  to  clavicles.  The  rash  and  flush  were  most  marked  in  the  area  cor- 
responding to  the  place  of  injection.  The  tongue  was  heavily  coated.  Could  not 
take  much  nourishment.    Grew  gradually  worse.    Died  September  9th. 

Site  of  the  Eruption. — A  large  flush  is  frequently  seen  on  the  parts 
around  the  point  of  injection,  from  whence  it  spreads  over  the  body.  It  is 
most  frequently  seen,  however,  on  the  abdomen,  chest,  and  buttocks.  The 
face  and  neck  are  seldom  involved.  There  is  itching  and  occasionally  the 
children  complain  of  intense  pain  in  the  joints.  Fever  usually  precedes 
the  eruption. 

Constitutional  symptoms^  such  as  vomiting,  diarrhoea,  headache,  mus- 
cular pains,  and  general  malaise,  are  noted.  Not  infrequently  when  hyper- 
pyrexia exists  there  is  delirium  or  convulsions  (Sevestre  and  Martin). 

In  urticaria  and  other  serum  rashes  both  the  itching  and  rash  will 
disappear  in  twenty  minutes  to  one-half  hour  after  one  subcutaneous  injec- 
tion of  ten  minims  of  1  to  1000  adrenalin  solution. 

Anaphylaxis. 

When  we  inject  the  first  dose  of  horse  serum  we  sensitize  the  guinea 
pig  or  rabbit,  and  the  serum  which  was  innocuous  to  the  animal  before  the 
first  injection  was  given  has  now  made  the  animal  so  hypersensitive  that 
the  second  injection  of  the  same  serum  is  not  only  very  poisonous,  but  may 
result  fatally.  Such  sensitive  reaction  when  found  in  human  beings  is 
called  anaphylaxis. 


518  THE  INFECTIOUS  DISEASES. 

Richet  demonstrated  the  fact  that,  although  an  animal  could  be  sensi- 
tized to  an  injection  of  a  non-toxic  dose  of  serum,  a  second  injection 
of  a  minimal  quantity  after  a  certain  interval  proved  fatal.  Later  Arthus, 
using  horse  serum,  obtained  similar  phenomena.  Von  Pirquet  and  Schick, 
working  along  similar  lines,  first  definitely  classified  the  symptom  complex 
which  develops  after  the  injection  of  therapeutic  sera  as  serum  disease. 
They  interpreted  this  as  a  reaction  to  a  specific  foreign  protein.  Briefly, 
the  symptoms  are  as  follows :  Various  skin  manifestations  of  urticarial  or 
erythema  multiforme  type,  fever,  oedema,  and  pain  in  the  joints.  They 
occur  usually  after  a  definite  period  of  incubation  of  eight  to  twelve  days. 

When  such  individuals  are  re-injected  the  incubation  period  is  reduced 
to  a  few  hours.  A  local  reaction,  called  the  Arthus  phenomenon,  is  present 
at  the  point  of  injection.  The  general  symptoms  are  of  short  duration  and 
sometimes  accompanied  by  collapse.  For  this  clinical  picture  von  Pirquet 
has  coined  the  vi^ord  "allergy."  The  sensitizing  substance  itself  has  been 
named  allergen,  which  from  the  findings  of  Eosenau  and  Anderson  is  identi- 
cal with  the  toxic  substance  of  serum.  It  has  been  shown  that  the  anaphy- 
lactic reaction  is  a  specific  one,  e.g.,  guinea  pigs  sensitized  with  horse  serum 
do  not  react  against  other  albuminous  bodies,  such  as  egg  albumin  or  milk. 
It  has  been  demonstrated  that  acquired  susceptibility  can  be  transmitted 
by  heredity. 

Nicolle  and  Otto  have  shown  that  a  condition  of  passive  anaphylaxis 
could  be  induced  by  treating  a  normal  animal  with  the  serum  of  an  anaphy- 
lacticized  animal.  Although  in  animal  experimentation  in  the  vast  majority 
of  instances  results  are  obtained  by  injection,  Eosenau  and  Anderson  suc- 
ceeded by  feeding  animals  in  obtaining  the  reaction  by  way  of  the 
alimentary  canal. 

WolfE-Eisner  believes  that  the  phenomena  of  anaphylaxis  are  of  central 
origin,  so  that  individuals  with  an  unstable  vasomotor  system  are  especially 
predisposed  to  the  more  severe  forms  of  hypersensitiveness.  Thus,  asthma, 
urticaria,  fibrinous  bronchitis,  and  membranous  enteritis  are  all  related  in 
their  symptomatology.  He  alludes  to  vasomotor  irritability,  which  causes 
eosinophile  secretions,  the  fibrinous  exudate,  and  the  spastic  condition  as 
well.  That  there  may  be  some  relationship  between  the  anaphylactic  condi- 
tion and  a  disturbance  of  tJie  internal  secretions  has  been  discussed  recently 
by  Hoffmann.  He  argues  because  urticaria  and  hay  fever  or  asthma  are 
frequently  associated  in  Ir^  [)erthyroidism  therefore  the  glands  of  internal 
secretion  must  influence  tlie  vessel-tone  by  their  products,  giving  rise  to 
anaphylactic  manifestations. 

The  Prevention  of  Anaphylactic  Shock. — According  to  Bedreska,  if  the 
serum  to  be  injected  is  heated  to  56°  C,  or  133°  F.,  then  not  only  can  the 
phenomena  be  diminished,  but,  as  a  rule,  averted. 

According  to  Vaughn,  if  a  preliminary  injection  of  as  little  as  0.1  or 


DIPHTHERIA.  519 

0.2  c.c.  of  serum  should  be  made  and  no  serious  symptoms  follow  within 
two  hours,  the  full  dose  can  then  be  given. 

Asthmatics  are  very  sensitive.  A  hypodermic  injection  of  atropine  will 
be  useful  to  prevent  anaphylactic  shock  in  a  patient  supposed  to  be  unduly 
sensitive  to  the  phenomena  of  anaphylaxis. 

Desquamatinn. — A  very  fine,  mealy  desquamation  follows  the  anti- 
toxin rash.  It  is  similar  to  the  measles  desquamation  (Berg).  A  ra^h  re- 
sembling measles  never  has  the  catarrhal  symptoms  which  we  always  note 
in  genuine  measles.  If,  however,  we  are  in  doubt  regarding  the  true  nature 
of  the  rash,  it  is  well  to  isolate  and  await  results  rather  than  to  expose 
children  to  the  risk  of  infection. 

Diagnosis. — The  diagnosis  of  diphtheria  affecting  the  pharynx,  ton- 
sils, and  nares  with  visible  membranes  is  quite  easily  made.  When,  how- 
ever, the  disease  affects  the  lower  respiratory  tract,  the  larynx,  trachea,  or 
bronchi,  the  diagnosis  will  be  rendered  more  difficult.  The  crucial  test  con- 
sists in  taking  a  culture  and  noting  the  bacteriological  result.  The  presence 
of  the  Klebs-Loeffler  bacillus  means  diphtheria,  especially  if  the  glands  of 
the  neck  are  swollen. 

We  must  not  infer  that  if  the  Klebs-Loeffler  bacillus  is  not  found 
our  case  is  of  a  non-diphtheritic  character.  A  technical  error,  such  as 
swabbing  a  healthy  surface  instead  of  an  infected  area,  may  be  the  cause  of 
a  negative  result.  Not  infrequently  in  the  most  malignant  forms  of  diph- 
tJieria,  nothing  tut  a  streptococcus  can  he  found.  This  is  especially  true 
when  complications  such  as  hroncho-pneumonia  are  met  with. 

Bacteriological  Diagnosis.- — Directions  for  Inoculating  Culture  Tubes 
with  the  Exudate  in  Cases  of  Suspected  Diphtheria:  The  child  should  be 
placed  in  a  good  light,  and  properly  held.  Eemove  the  swab  from  its  tube. 
Depress  the  tongue  with  a  spoon  in  the  left  hand.  With  the  swab  in  the 
right  hand  rub  firmly  but  gently  against  any  visible  membrane  on  the  ton- 
sils or  in  the  pharjTix.  Withdraw  the  cotton  plug  from  the  culture  tube. 
Insert  the  swab,  and  rub  it  thoroughly  but  gently  back  and  forth  over  the 
entire  surface  of  the  blood  serum.  Do  not  allow  the  swab  to  touch  any- 
thing except  the  throat  of  the  patient  and  the  surface  of  the  serum.  Do 
not  push  the  swab  into  the  serum  or  break  the  surface  in  any  way.  Ee- 
place  the  swab  in  its  own  tube;  plug  both  tubes;  fill  out  the  blank  forms 
which  accompany  each  tube,  and  send  to  a  culture  station.^ 

Out  of  1857  cases  of  diphtheria  admitted  to  the  Willard  Parker  Hos- 
pital during  1910,  426  showed  negative  cultures  on  admission,  and  1431 
showed  positive  cultures  on  admission.  The  total  number  of  croup  cases 
admitted  was  403. 

^  The  New  York  Department  of  Health  has  a  series  of  culture  stations  in 
various  drug  stores.  At  these  stations  sterile  culture  tubes  are  supplied  to  the 
physician  and  the  same  are  also  collected  daily  after  inoculation.  The  Depart- 
ment of  Health  furnishes  material,  including  examination  and  report,  free  of  charge. 


530  THE  INFECTIOUS  DISEASES. 

533  eases  showed  tonsillar  exudate. 
348  cases  showed  laryngeal  exudate. 
160  eases  showed  tonsillar  and  pharyngeal  exudate. 

39  cases  showed  tonsillar,  pharyngeal,  and  nasal  exudate. 

36  eases  showed  pharyngeal  exudate. 

23  cases  showed  nasal  exudate. 
/ 

Tli&  Schick  Reaction?- — The  use  of  the  Schick  reaction,  as  well  as  its 
practical  application,  has  heen  popularized,  hy  Dt.  A.  Zingher,  of  the  New 
York  Health  Department  Eesearch  Laboratory.  In  a  person  susceptible  to 
diphtheria,  the  blood  does  not  contain  antitoxin,  and  the  toxin  used  for 
testing  produces  a  reaction.  This  reaction  is  visible  within  twenty-four  to 
thirty-six  hours  after  such  test  is  made.  It  remains  three  or  four  days,  is 
of  a  pinkish  or  reddish  color,  and  at  the  end  of  one  week  fades  into  a 
bronze  color,  which  may  remain  visible  two  weeks  or  even  longer. 

It  has  been  found  that  85  per  cent,  of  infants  within  the  first  year  are 
negative  with  tliis  test.  Between  the  second  and  fifth  years;,  however,  35 
per  cent,  of  children  are  immune,  5  per  cent,  being  susceptible.  Bletween 
the  fifth  and  tenth  years  75  per  cent,  are  immune. 

The  Schick  test  can  also  be  used  to  differentiate  true  diphtheria  from 
other  membranous  exudates.  If  a  negative  reaction  occurs,  it  shows  the 
presence  of  sufficient  antitoxin  in  the  blood,  hence  a  diagnosis  of  diphtheria 
should  not  be  made. 

Antitoxin  given  intramuscularly  before  or  simultaneously  with  the 
toxin  usually  completely  inhibits  the  Schick  reaction. 

The  technique  of  the  method  is  as  follows :  After  an  area  of  skin  on 
the  forearm  has  been  cleansed  with  alcohol,  the  latter  is  encircled  with  the 
thumb  and  index  finger,  and  the  skin  held  tense  between  them.^  The 
needle  is  dipped  into  the  bottle  of  pure,  undiluted  diphtheria  toxin  and 
immediately  inserted  intradermally  and  not  subcutaneously.  The  needle  is 
an  ordinary  hypodermic  bent  at  a  distance  of  one-fourth  inch  from  its  point 
so  as  to  make  an  angle  of  about  170  degrees.  The  angle  aids  in  inserting 
the  needle  intradermally. 

The  toxin  used  by  Schick  and  his  associates^  is  a  dilution  of  such 
strength  that  0.1  cubic  centimeter  equals  %q  of  the  lethal  dose  for  a  250 
Gm.  guinea-pig.  The  lethal  dose  of  the  toxin  which  Schick  uses  is  0.005, 
and  hence  he  injects  0.1  c.c.  of  a  1 :  1000  dilution.  In  those  who  react  an 
area  of  reddening  and  infiltration  develops  within  twenty-four  hours,  reach- 
ing its  maximum  in  forty-eight  hours,  and  which  heals  with  scaling  and  a 
characteristic  central  pigmentation.  Although  the  reaction  is  similar  to  the 
local    tuberculin    reaction,    its    interpretation    is    directly    opposite.      The 


^  Park,  Zingher,  and  Serota,  Jour.  Amer.  Med.  Assoc,  September  5,  1914. 
^Koplik  and  Unger,  Jour.  Amer.  Med.  Assoc.,  April  15,  1916. 
*Veeder,  Amer.  Jour,  of  Dis.  of  Children,  August,  1914. 


PLATE  XXriI 

A 


A — Shows  four  tpyical  positive  Schick  reactions  of  varying  degrees  of  intensity 
forty-eight  hours  after  test,  a  is  a  strongly  positive  reaction,  with  vesicnlation  of 
the  surface  hiyers  of  the  epithelium,  which  is  seen  occasionally  in  individuals  who 
have  practically  no  antitoxin;  b  and  c  are  positive  reactions;  d,  a  moderately 
positive  reaction. 

B 


B — Shows,  a  fading  positive  Schick  reaction  one  to  four  weeks  after  test  in 
various  stages  of  scaling  and  ])ignu'iitatioii.  n  sliows  rediu^ss,  svaliug  and  heginniu'i' 
])igineiitation  after  one  week:  h  and  r,  ])ignu'ntat ion  after  two  and  three  we(>ks; 
(/.  fnint  pignientat'on  after  four  weeks.  (After  Park  and  Zingher,  Amer.  Jour.  Dis. 
Children.  April.  191(5.) 


PLATE  XXIV 


Shows  t\vo  pspudoreactions  forty-eiglit  liours  aft^r  test,  and  a  combined  reaction. 
a,  mild;  h,  marked;  c,  a  combined  jiositivc  and  ps<-udoreaction.  (After  Park  and 
Zingber.) 


DIPHTHERIA. 


521 


diphtheria  toxin  is  a  direct  toxic  agent  and  by  control  tests  of  the  blood- 
serum  it  has  been  found  tbat  a  negative  reaction  is  always  associated  vjith 
the  presence  of  diphtheria  antitoxin  in  the  blood  of  the  person  tested. 
While,  as  a  rule,  a  positive  skin  reaction  is  an  indication  of  the  absence 
of  antibodies,  some  persons  react  positively  for  some  unexplained  reason 
who  possess  a  greater  amount  of  antitoxin  in  the  blood  than  0.03  units  per 
cubic  centimeter. 

It  has  been  found  that  if  a  negative  reaction  follows  the  injection  of 
a  0.1  cubic  centimeter  of  a  1 :  1000  dilution  of  toxin,  the  individual  tested 
has  at  least  0.031  units  of  antitoxin  per  cubic  centimeter  in  his  blood  when 


Fig.  163. — Pneumonia  Complicating  Diphtheria.  (Kind  assistance  of 
Dr.  Edward  H.  Sparkman,  Jr.,  at  the  Willard  Parker  Hospital.)  A. 
Starting  point  of  pneumonia,  showing  extent  on  third  day.  B.  Focus 
which  developed  three  days  after  A,  showing  extent  on  third  day  of  the 
new  focus.      (Original.) 

tested  by  Homer's  method.  A  person  with  a  higher  concentration  of  anti- 
toxin will  react  negatively  to  a  smaller  dilution  of  antitoxin  and  vice  versa. 
Thus  the  outcome  and  the  degree  of  reaction  are  dependent  on  two  factors — • 
the  strength  of  the  toxin  used  and  the  presence  of  antitoxin  in  the  blpod.^, 

As  there  is  no  antitoxin  present  in  the  blood  in  acute  diphtheria,  the 
use  of  the  reaction  for  diagnostic  purposes  has  been  suggested.  Tbus  in  a 
suspected  case  or  questionable  diagnosis  a  negative  reaction — indicating  the 
presence  of  antitoxin,  would  speak  against  the  diagnosis  of  diphtheria. 

Differential  Diagnosis. — In  the  very  beginning  of  the  disease,  before 
the  appearance  of  a  pseudo-membrane,  the  diagnosis  is  beset  with  difl&culty. 
Thus,  an  acute  catarrhal  angina  will  show  symptoms  similar  to  those  of 
diphtheria. 

Pre-memhranous  Diphtheria. — When  a  child  has  been  exposed  to  diph- 
theria, the  careful  daily  inspection  of  the  nose  and  throat  is  demanded.    At 


522  THE  INFECTIOUS  DISEASES. 

the  slightest  rise  of  temperature  associated  with  an  intense  congestion  of 
the  pharynx  and  tonsils,  antitoxin  should  be  injected. 

The  diagnosis  of  diphtheria  can  usually  be  made  twenty-four  to  forty- 
eight  hours  before  the  membranes  are  visible.  ■  A  culture  should  always  be 
taken,  but  too  much  reliance  must  not  be  placed  on  the  bacteriological 
findings,  because  the  Klebs-Loeffler  bacillus  may  have  invaded  the  deeper 
structures  and  not  be  present  on  the  surface;  therefore,  cultures  should  be 
taken  daily  until  the  disease  can  positively  be  excluded.  The  cervical  glands 
are  usually  swollen. 

Thrush  sometimes  resembles  diphtheria,  but  can  be  differentiated  by 
the  fact  that  the  small,  whitish  spots  resembling  curdled  milk  are  scattered 
over  the  cheeks,  lips,  tongue,  and  gums,  in  addition  to  the  uvula  and 
pharjTix. 

Ulcerative  tonsillitis^  resembling  diphtheria  has  been  described  by  Yin- 
cent.  In  this  condition  there  is  no  tendency  to  spread.  There  is  an  absence 
of  croup,  and  a  culture  taken  shows  the  Vincent  bacillus  instead  of  the 
Klebs-Loeffler  bacillus. 

Peritonsillar  Aiscess. — In  this  condition  we  meet  with  a  swelling  or 
bulging  forward  of  the  affected  parts.  The  uvula  is  sometimes  displaced. 
There  are  very  many  active  local  s}Tnptoms,  such  as  pain  and  difficulty 
in  swallowing,  and  a  nasal  tone  of  voice.  Not  infrequently  when  an  at- 
tempt to  swallow  is  made  the  fluid  regurgitates  through  the  nose.  When 
children  are  old  enough  to  describe  subjective  symptoms,  they  will  complain 
of  chills  and  fever.  The  temperature  is  usually  high,  ranging  from  102°  to 
105°  F.  The  active  symptoms  subside  the  moment  pus  is  relieved.  Nature 
frequently  gives  a  spontaneous  evacuation  of  the  pus.  At  other  times  it  is 
wiser  to  give  relief  by  making  an  incision  and  emptying  the  pus.  A  culture 
taken  in  this  condition  does  not  show  the  presence  of  the  Klebs-Loeffler 
bacillus. 

Follicular  Tonsillitis. — In  this  condition  more  than  in  any  other  form 
of  disease  we  must  ie  careful  regarding  a  positive  opinion.  There  are 
follicular  forms  of  diphtheria  involving  the  lacunce  of  the  tonsils  which 
clinically  so  resemble  diphtheria  that  even  an  expert  cannot  differentiate 
them. 

Table  No.  51. — Complications  Observed  at  the  Willard  Parker  Hospital. 

1910  1911 

Number  of  Cases  1857  1558 

Eye  Complications. 

Conjunctivitis    (Catarrhal)     105  51 

Conjunctivitis   (Diphtheritic) 7  3 


^Read  article  on  "Tonsillitis.' 


DIPHTHERIA.  523 

Ear  Complications. 

Mastoiditis    (Operative)     2 

Otitis  Media  135  112 

Nasal  Complications. 
Paralysis    8  13 

Throat   Complications. 

Paralysis    (Pharyngeal) 112  28 

Peritonsillar  Abscess 14  9 

Cervical  Adenitis    318  101 

Pulmonary  Complications. 

Broncho-pneumonia   334  201 

Lobar  Pneumonia    6  5 

Empyema     5  2 

Cardiac  Complications. 

Pericarditis   2  2 

Myocarditis   110  100 

Endocarditis      40 

General  Complications. 

Nephritis    20  30 

Delirium    31  10 

Vaginitis    110  129 

Arthritis    5  6 

Convulsions   5  5 

Syphilis    4 

The  clinical  manifestations  of  the  benign  form  of  follicular  tonsillitis 
have  already  been  described  in  the  article  on  "Follicular  Tonsillitis/' 

The  differential  diagnosis  depends  on  the  presence  or  absence  of  the 
Klebs-Loeffler  bacillus. 

Complications/ — The  most  frequent  complication  met  with  is  'broncho- 
pneumonia. More  deaths  occur  from  this  than  from  any  other  complica- 
tion. It  is  usually  the  extension  of  the  disease  from  the  larynx  to  the 
bronchi.  When  a  septic  form  of  diphtheria  exists  broncho-pneumonia  usu- 
ally accompanies  it.     (See  chapter  on  "Pneumonia.") 

Pleurisy  with  serous  effusion  frequently  complicates  this  disease. 

Empyema  not  infrequently  complicates.  A  number  of  these  cases  have 
been  seen  by  me  during  my  service  at  the  Willard  Parker  Hospital. 

Otitis  is  occasionally  met  with  as  a  complication  of  diphtheria.  It  is 
usually  the  result  of  a  streptococcus  infection  through  the  nose  or  throat 
into  the  Eustachian  tube. 

Myocarditis  is  the  most  frequent  form  of  heart  complication  met  with 
in  diphtheria. 

Endocarditis  and  pericarditis  are  also  seen  in  severe  types  of  this 
disease. 


*  For   a   detailed  description  of   the   various   complications,   the   reader   is   re- 
ferred to  the  special  articles  on  "Otitis,"  "Empyema,"  etc. 


524 


THE  INFECTIOUS  DISEASES. 


Meningitis  is  not  often  seen,  though  I  have  seen.  3  such  cases  out  of 
a  total  of  35  at  the  Willard  Parker  Hospital  during  my  service.  About 
10  per  cent,  of  all  septic  cases  have  meningitis. 

Cerebral  thromdosis  and  em'boUsm  occasionally  complicate  diphtheria, 
and  result  in  hemiplegia,  convulsions,  or  aphasia. 

Thrombosis  of  the  pulmonary  artery  of  the  heart  may  cause  sudden 
death.  This  is  usually  accompanied  by  feeble  heart's  action  the  result  of 
degenerative  changes  in  the  muscular  walls  (Holt). 


190^.. 

DATES  OF  03SERVATI0NS.                                            | 

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Fig.    164. — ^Temperature  Chart  from  a  Case  of  Diphtheria  complicated  by 
Broncho-pneumonia   (Step-ladder  Type  of  Fever).      (Original.) 

Ecemorrhages  occur  quite  often.  Bleeding  from  the  nose  and  from  the 
ear,  also  blood  in  the  urine  and  blood  in  the  stools,  has  frequently  been  seen 
by  me.    These  cases  are  of  the  most  severe  type  and  usually  end  fatally. 

When  the  hfemorrhagic  type  is  seen  early,  and  the  toxin  in  the  circula- 
tion rapidly  neutralized  by  the  intravenous  injection  of  antitoxin,  the 
chances  of  recovery  are  greatly  increased. 

Purpuric  spots  similar  to  that  form  of  purpura  met  with  in  rheumatism 
were  seen  by  me  in  septic  cases,  all  of  which  ended  fatally. 

Acute  Renal  Congestion.— This  usually  accompanies  severe  diphtheria. 
In  many  instances  it  is  a  forerunner  of  an  acute  nephritis.     The  earliest 


DIPHTHERIA. 


525 


symptoms  noted  are  albumin  and  red  blood  cells.  At  times  the  urine  may  be 
scanty.  The  toxin  filtering  through  the  system  attacks  the  kidneys  as  well 
as  the  heart,  and  it  is  important  to  make  daily  examinations  of  the  urine, 
80  that  nephritis,  if  present,  can  readily  be  detected. 

The  action  of  the  kidneys  during  diphtheria  is  as  important  as  the 
action  of  the  bowels,  because  the  retention  of  toxin  may  result  fatally. 

If  the  urine  is  scanty  the  temperature  will  be  higher,  and,  therefore,  a 
mild  diuretic,  such  as  5  to  10  grains  of  citrate  of  potassium,  is  indicated. 


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Fig.    165. — Temperature  Chart  from  a  Case  of  Diphtheria  complicated  by 
Lobar  Pneumonia.      (Original.) 

The  application  of  a  warm-water  bag  over  the  kidneys  also  stimulates 
diuresis.  Dry  cupping  over  the  kidneys  repeated  every  twelve  hours  will 
stimulate  the  flow  of  urine.  Moderate  quantities  of  water  should  be  given 
to  flush  the  kidneys  and  eliminate  toxin. 

Nephritis'^  is  usually  met  with  in  septic  cases,  although  it  may  follow 
as  a  complication  of  the  milder  form  of  this  disease.  Traces  of  albumin 
are  frequently  found  during  the  course  of  diphtheria.  This  does  not 
necessarily  imply  that  we  are  dealing  with  nephritis.  The  presence  of  casts, 
in  addition  to  the  albumin,  or. possibly  blood,  is  necessary  to  strengthen  the 
diagnosis  of  nephritis. 


*An  excellent  illustration  of  nephritis  complicating  diphtheria  is  described  in 
the  article  on  "Nephritis." 


526 


^HE   lifFEOTIOUS   DISEASES. 


Diarrhcea  due  to  a  follicular  ileo-colitis  or  acute  gastric  catarrh  fre- 
quently complicates  diphtheria. 

Diarrhoea,  when  present,  is  nature's  method  of  eliminating  toxins  and 
should  be  looked  upon  as  an  aid  in  cleansing  the  system  rather  than  as  a 
complication.  When  diarrhoea  is  not  present  and  the  bowels  are  constipated, 
then  sufficient  hydragogue  cathartics,  such  as  calomel  or  compound  jalap 
powder,  should  be  prescribed  to  produce  loose  bowels. 

Diphtheritic  Gastritis. — When  membranous  gastritis  occurs  it  is  usu-' 
ally  a  diphtheritic  gastritis. 

Diphtheritic  omphalitis  is  described  in  Chapter  III,  Part  II. 

When  membranous  enteritis  complicates  diphtheria  it  is  usually  the 
result  of  a  streptococcus  or  Klebs-Loeffler  infection. 


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Fig.    166. 


-Temperature  Chart  from  a  Case  of  Diphtheria  complicated  by 
Otitis  and  Meningitis.     Fatal.     (Original.) 


Profound  anaemia  usually  follows  diphtheria.  This  is  due  to  the  effect 
of  the  toxins  in  the  blood  causing  the  destruction  of  the  red  corpuscles. 

Post-diphtheritic  Paralysis.— Toxseiriia,  caused  by  absorption  of  the 
toxins  generated  by  the  Klebs-Loeffler  bacillus,  if  not  neutralized  either  by 
an  injection  of  antitoxin  or  by  Nature's  own  production  of  antitoxin,  fre- 
quently causes  paralysis.  This  paralysis  usually  aifects  individual  muscles 
or  groups  of  muscles.  In  this  manner  the  heart,  which  is  a  muscular  organ, 
is  frequently  paralyzed,  resulting  in  death.  When  the  toxin  aifects  the 
respiratory  centers  it  may  result  in  paralysis,  causing  death  by  asphyxia.  In 
addition  to  the  paralytic  effect  of  this  toxin  on  the  muscles  and  nerves, 
degenerative  changes  are  brought  about  by  the  influence  of  this  poison. 
Thus  it  is  that  the  toxin  in  the  system  will  frequently  irritate  an  otherwise 
healthy  kidney  and  set  up  a  toxic  nephritis. 


JDIPHTHERIA,  527 

From  tlie  foref^oing  we  can  see  that  the  poison  generated  by  the  Klebs- 
Loeffler  bacillus  is  certainly  a  serious  factor  whicli  must  be  dealt  with  very 
energetically. 

A  study  of  recorded  cases  of  paralysis  shows  that  between  10  and  30 
per  cent,  of  all  cases  of  diphtheria  are  followed  by  paralysis.     Woodward 
studied  7832  cases  of  diphtheria;  of  these  13G2  had  post-diphtheritic  paral- 
ysis.   Myers,  in  the  London  Lancet,  1900,  studied  1316  cases  of  the  disease, 
in  which  275  cases,  or  about  21  per  cent.,  had  palsy. 
110  cases  affected  the  palate, 
69  cases  were  cardiac, 
21  eases  diaphragmatic. 

There  are  four  palsies  due  to'  severe  toxaemia ;  they  occur  in  the  follow- 
ing order :  palatal,  ocular,  cardiac,  and  diaphragmatic. 

Paralysis  is  most  frequently  found  in  children  between  the  second  and 
sixth  years.  Usually  during  the  second  week  following  diphtheria,  when 
the  child  is  convalescent,  emaciation  of  the  extremities  will  be  noticed.  If 
the  muscles  of  the  trunk  are  involved,  there  will  be  emaciation  of  the  thoracic 
muscles,  regurgitation  of  liquids  through  the  nose,  and  a  nasal  twang  in 
the  voice.  There  is  marked  difficulty  in  walking  or  climbing  stairs  in  other 
cases;  the  child  waddles  and  appears  weak,  falls  easily,  and  staggers  as  in 
ataxia.  In  severe  cases  the  child  is  unable  to  raise  its  head.  The  sphincter 
of  the  rectum  and  bladder  may  become  paralyzed,  resulting  in  involuntary 
urination  or  obstinate  constipation. 

Paralysis  of  the  extremities  may  be  added  to  paralysis  of  the  respira- 
tory muscles  or  of  the  heart.  The  knee-jerk  may  be  diminished  or  absent. 
The  absence  of  the  knee-jerk  indicates  some  change  in  the  peripheral  neu- 
ron. The  special  heart  symptoms  indicating  cardiac  paralysis  are  irregu- 
larity of  heart's  action  or  a  gallop  rhythm,  bradycardia,  tachycardia,  lower- 
ing of  the  temperature  (usually  subnormal),  vomiting;  dilatation  of  the 
heart,  a  short  first  sound  with  systolic  murmur  at  apex,  blueness  of  the  lips, 
and  cold  extremities. 

"Monicatide  divided  diphtheritic  paralysis  into  four  groups:  Those 
showing  (1)  purely  muscular  change  without  nerve  involvement;  (2) 
polyneuritis;  (3)  lesions  of  the  spinal  cord,  which  were  either  localized  in 
the  gray  matter,  leading  to  atrophy  of  muscles,  or  involved  the  white  matter 
of  the  cord  in  a  similar  way  to  that  seen  in  locomotor  ataxia  or  multiple 
sclerosis,  and  (4)  cerebral  haemorrhage  cliiefly  due  to  circulatory  change. 
Thisi  classification  is  accepted  by  many  of  to-day.  To  be  scientifically  cor- 
rect, however,  tlie  fourth  group,  i.e.i,  tlie  cerebral  palsies,  should  not  be 
classed  as  a  palsy  due  to  a  diphtlieritic  toxin,  inasmuch  as  the}''  are  acci- 
dental. Strictly  speaking,  the  term  diphtheritic  palsy  should  be  applied  to 
tliose  palsies  only  which  are  due  to  direct  action  of  the  diphtheritic  toxin."-' 

A  child,  4  years  old,  was  seen  during  my  service  at  the  Willard  Parker  Hos- 
pital. He  had  suffered  with  severe  tonsillar  and  pharyngeal  diphtheria.  The 
exudate  was   unusually   thick.     The   resident   physident  called   my   attention  to   a 


528  THE   INFECTIOUS  DISEASES. 

regurgitation  of  the  liquids  througli  the  nose  and  to  the  nasal  twang  in  speaking. 
On  examining  the  throat,  all  evidences  of  ;iiphtheria  had  disappeared.  The  tip  of 
the  uvula,  instead  of  hanging  in  the  median  line,  pointed  toward  the  left  side.  As 
this  case  was  a  severe  type  of  diphtheria  we  were  not  surprised  to  see  the  paralysis. 
Strychnine  was  given.     The  case  recovered. 

When  diphtheria  has  preceded  an  attack  of  paralysis.,  the  diagnosis 
is  easily  made.  Emaciation  is  general,  as  a  rule,  and  not  confined  to  a 
simple  group  of  muscles. 

The  disease  is  sometimes  mistaken  for  acute  anterior  poliomyelitis, 
The  onset  of  the  latteri  is  sudden,  and  is  usually  preceded  by  fever.  The 
absence  of  a  history  of  diphtheria  aids  in  establishing  the  diagnosis. 

In  275  cases  reported  by  Myers,  80  died,  or  291  per  cent. 

Course. — A  mild  case  of  diphtheria  will  show  exfoliation  of  the  exudate 
on  the  tonsils  and  pharynx  about  twenty-four  to  forty-eight  hours  after  a 
sufficient  dose  of  antitoxin  has  been  injected.  In  four  or  five  days  after  the 
beginning  of  illness,  the  disease  usually  disappears,  so  that  there  is  no 
visible  evidence  of  the  same. 

In  a  severe  case^  (male,  8  years  old)  seen  by  me  in  October,  1904,  in  the  wards 
of  the  Willard  Parker  Hospital,  the  exudate  completely  covered  the  fauces.  The 
tonsils,  uvula,  and  pharynx  were  covered  with  one  large  mass  of  pseudo-membranes. 
The  cervical  glands  were  very  much  enlarged.  The  case  looked  decidedly  septic. 
An  injection  of  5000  units  of  antitoxin  was  given  on  the  first  day,  soon  after  ad- 
toission  to  the  hospital.  A  second  injection  of  5000  units  was  given  on  the  second 
day.  A  third  injection  of  5000  units  was  given  on  the  third  day.  A  fourth 
injection  of  5000  units  was  given  on  the  fourth  day,  so  that  20,000  units  were  admin- 
istered during  the  first  four  days  after  admission  to  the  hospital.  The  membrane 
exfoliated,  the  swelling  of  the  glands  disappeared  and,  one  week  after  his  admission, 
the  throat  was  clear  and  he  was  convalescent.^ 

A  mild  case  of  diphtheria  may  last  from  five  to  eight  days.  Severe 
types  may  last  many  weeks.  No  case  of  diphtheria  should  be  considered 
to  have  run  its  course  until  the  heart's  action  is  normal  and  the  general 
condition  good.  Sudden  death  may  come  from  over-exciting  a  weakened 
or  damaged  heart  if  proper  caution  is!  not  used. 

Prognosis. — 'The  uncertainty  of  this  disease  and  the  ease  with  which 
complications  follow  must  be*  taken  into  consideration  ia  giving  the  prog- 
nosis in  a  given  case  of  diphtheria.  A  child  suffering  from  diphtheria, 
who  was  brought  up  in  unsanitary  surroundings  or  one  deprived  of  breast- 
milk,  will  suffer  much  more  than  one  favored  with  the  opposite  conditions. 
Such  factors  are  important  in  giving  an  opinion.  A  child  with  rickets  is 
more  liable  to  succumb  to  an  infection  from  diphtheria  and  may  possibly 


^  The  colored  illustration  D,  Plate  XXI,  was  drawn  from  this  case  at  the  bed- 
side in  the  Willard  Parker  Hospital. 

"  This  case  was  reported  by  me  at  a  meeting  of  the  New  York  State  Medical 
Association  held  October  19,  1904. 


DIPHTHERIA.  529 

die,  when  a  child  with  a  strong  iioniiai  body  and  liealthy  internal  organs 
will  recover.  In  tliis  disease  we  therefore  note  that  it  is  the  "survival  of 
.the  fittest."  When  diphtheria  follows  typhoid,  or  when  it  is  a  complica- 
tion of  a  severe  systemic  infection,  like  scarlet  fever,  then  great  care  should 
be  exercised  in  venturing  an  opinion  as  to  the  probable  outcome  of  the 
attack. 

The  guide  in  estimating  the  prognosis  of  any  case  of  diphtheria  should 
always  be  the  condition  of  tlie  heart.  A  very  rapid  pulse  or  a  gradually 
increasing  pulse-rate  are  bad  signs.  The  temperature  cannot  be  looked 
upon  as  the  rAost  impotent  factor  in  determining  the  outcome  of  this  con- 
dition. I  have  seen,  cases  of  diphtheria  in  hospital  as  well  as  in  private 
practice  where  normal  temperatures  prevailed  and  still  septic  conditions 
were  positive.  Such  cases,  showing  a  low  inflammatory,  type  having  slight 
elevations  of  temperature,  rarely  recover.  The  prognosis  is  also  influenced 
by  the  time  at  which  the  treatment  was  commenced.  When  antitoxin  is 
injected  on  the  first  or  second  day  of  the  disease  the  outcome  is  brighter 
naturally  than  when  the  disease  extends  without  specific  treatment.  The 
mortality  is  greatest  in  children  under  2  years  of  age. 

Prophylaxis. — In  no  disease  should  we  be  more  careful  than  in  diph- 
theria. Strict  isolation  of  all  cases  should  be  enforced,  so  that  no  trans- 
mission of  the  disease  can  take  place. 

In  New  York  City  children  suffering  from  diphtheria  are  excluded 
from  school  for  a  minimum  period  of  one  week  and  must  not  be  readmitted 
until  all  symptoms  have  disappeared  and  the  culture  is  negative.  If  quaran- 
tine is  observed,  children  and  others  who  have  been  immunized  against  the 
disease,  and  cultures  from  whose  throats  do  not  show  diphtheria  bacilli,  may 
return  to  school.  If  children  or  others  in  the  family  are  immediately  re- 
moved to  another  address  and  culture  taken  from  nose  and  throat  is 
negative,  they  may  be  readmitted.  If  continuing  to  reside  at  home  and  the 
above  precautions  are  not  taken,  they  cannot  be  readmitted  until  the  case 
has  been  officially  discharged. 

Visitors  may  be  permitted  in  a  room  where  diphtheria  exists,  providing 
they  do  not  come  into  direct  contact  with  the  patient. 

The  vital  point  to  be  considered  is  how  to  prevent  complications.  The 
question  arises:  Can  complications  be  prevented  by  proper  treatment? 
They  certainly  can  if  treatment  is  commenced  early  in  the  disease.  We 
must  carefully  watch  all  the  functions  of  the  body  and  stimulate  those  that 
do  not  seem  to  act;  The  emunctories  are  the  most  important  which  require 
watching.  If  the  kidneys  are  found  secreting  very  small  quantities  of  urine, 
then  we  can  be  reasonably  sure  that  the  toxins  stored  in  the  kidneys  will 
cause  serious  damage.  When  therefore  a  scanty  secretion  of  urine  is  met 
with  it  will  at  once  call  for  active  diuretic  treatment.  The  rule  I  have 
always  followed  is  to  stimulate  with  mild  diuretic  treatment  from  the  be- 

34 


530  THE  INFECTIOUS  DISEASES. 

ginning,  and  secure  a  copious  secretion  of  urine.  The  same  is  true  regard- 
ing the  condition  of  the  bowels.  In  no  disease  is  it  as  important  to  have 
food  assimilated  and  to  have  proper  evacuation  as  in  the  course  of  the 
treatment  of  diphtheria. 

We  eliminate  large  quantities  of  toxins  by  the  bowel,  the  skin,  and 
the  kidneys;  hence  we  have  it  in  our  means  to  hasten  recovery  and  at  the 
same  time  guard  against  storing  up  poison  in  the  blood. 

The  clothing  should  be  warm.  The  child  should  not  be  exposed  while 
bathing.  We  must  guard  against  draughts,  as  we  know  there  is  a  peculiar 
predilection  for  pneumonia  in  the  course  of  diphtheria.  The  urine  must 
frequently  be  examined.  The  examination  must  not  only  be  chemical, 
but  microscopical.  The  moment  we  find  our  case  complicated  by  nephritis, 
the  same  should  be  given  proper  attention. 

Isolation. — ^Very  frequently  children  have  Klebs-Loeffler  bacilli  in  the 
throat — so-called  culture  cases — in  the  premembranous  stage  of  the  dis- 
ease. Some  of  these  develop  diphtheria  of  the  most  virulent  type.  A  safe 
rule,  therefore,  is  to  insist  on  the  isolation  of  every  child  having  the  Klehs- 
Loeffler  haciUus  in  the  secretions  of  the  nose  and  throat,  for  weeks  and 
months  if  necessary,  until  a  swab  from  the  throat  shows  an  absence  of  the 
Klebs-Loeffler  bacillus,  to  guard  against  possible  development  of  fatal  diph- 
theria. 

The  finding  of  diphtheria  bacilli  in  the  throat  without  marked  clinical 
indications  of  diphtheria  has  no  significance,  according  to  Behring.^ 

He  asserts  that  about  10  per  cent,  of  the  entire  population  carry  diph- 
theria bacilli  in  their  throats  without  resulting  infection.  The  bacilli  have 
lost  their  virulence,  or  else  the  individual  possesses  a  natural  immunity. 
He  considers  all  bacteria  with  the  morphological  characteristics  of  LoefSer's 
bacillus  true  diptheria  bacilli,  but  he  would  differentiate  a  simple  angina, 
rhinitis,  or  conjunctivitis  from  diphtheria,  even  with  diphtheria  bacilli 
numerous  in  the  organ  involved,  if  there  were  no  general  symptoms  of 
diphtheria.  He  af&rms  that  it  is  useless  and  nonsensical  to  isolate  persons 
who  have  been  exposed  to  diphtheria.  It  is  impossible  to  free  people  from 
the  bacilli  or  to  keep  them  permanently  free.  Infection  results  from  a  pre- 
disposition, which  is  in  turn  due  to  a  lack  of  antitoxic  serum  in  the  blood. 
The  antibodies  which  undoubtedly  exist  in  the  blood  of  numerous  indi- 
viduals are  probably  produced  by  the  vital  activity  of  avirulent  diphtheria 
bacilli  in  their  throats.  He  consequently  suggests  that  it  might  be  possible 
to  induce  auto-immunization  by  transplanting  avirulent  diphtheria  bacilli 
into  the  throats  of  other  human  beings.  The  comparative  immunity  of 
physicians  to  diphtheria  may  be  due  to  the  repeated,  unconscious  inocula- 
tion with  small  doses  of  the  virus.    Extensive,  systematic  preventive  inocu- 


^  Therapie  der  Gegenwart   (Berlin). 


DIPHTHERIA.  531 

lation  with  antitoxin  would  induce  a  natural  immunity  to  the  disease  and 
entail  the  final  disappearance  of  diphtheria. 

While  the  view  maintained  by  Behring  is  interesting,  it  certainly  does 
not  conform  to  modem  clinical  experience.  No  child  should  be  permitted 
at  large  with  diphtheria  bacilli,  owing  to  the  possible  fatal  result  entailed 
thereby. 

Immunization,  in  Diphtheria. — Immunity  in  the  Nursling:  There 
seems  to  be  an  immunity  conferred  upon  the  nursling.  This  may  be  due 
to  the  antitoxic  properties  of  serum  contained  in  the  mother's  milk. 

Diphtheria  rarely  attacks  nurslings,  but  most  frequently  attacks  infants 
brought  up  by  hand-feeding — the  bottle  babies.  It  is  most  frequently  met 
with  between  the  second  and  eighth  years.  The  disease  may  recur  and  has 
been  known  to  attack  patients  three  or  four  and  even  more  times. 

How  to  Immunize. — When  a  case  of  diphtheria  occurs  in  a  family  in 
which  there  are  apparently  very  healthy  children,  then  immunity  can  be 
conferred  upon  them  by  giving  an  injection  of  antitoxin.  This  immimity 
is  in  the  nature  of  prophylactic  treatment.  The  average  dose  required  for 
a  child  from  1  to  5  years  is  500  to  1000  units.  For  older  children,  from 
'5  to  13  years,  1000  antitoxin  units  may  be  injected.  No  further  treat- 
ment will  be  necessary  after  the  injection.  All  aseptic  precautions  which 
are  described  in  the  article  on  the  "Injection  of  Antitoxin"  must  be  used 
whether  we  inject  a  large  or  a  small  dose  of  antitoxin.  It  must  not  be  sup- 
posed that  because  an  immunizing  dose  of  antitoxin  has  been  injected 
such  a  child  may  then  be  exposed  to  this  disease  with  impunity.  Experi- 
ence has  shown  that  when  children  have  been  given  an  immunizing  dose 
of  antitoxin  and  are  immediately  isolated,  as  a  rule  they  do  not  take  the 
disease.  On  the  other  hand,  if  children  are  permitted  to  remain  in  the 
same  room  with  a  case  of  malignant  diphtherial,  it  is  quite  plausible  to 
assume  that  they  will  take  the  disease,  even  though  an  immunizing  dose 
of  serum,  has  been  injected.  Immunity  is  usually  conferred  for  a  period 
of  two  or  three  weeks.  It  is  a  good  plan  to  repeat  this  same  immunizing 
dose  of  antitoxin  if  diphtheria  still  prevails  in  the  househc^ld  three  weeks 
after  the  first  injection  has  been  given.  Children  receiving  an  immunizing 
dose  should  be  treated  as  though  they  were  perfectly  well  children.  There 
should  be  no  restriction  to  their  diet  and  they  should  be  peimitted  to  romp 
and  play  in  the  open  air,  and  receive  their  bath  just  as  thougii  no  injection 
had  been  given. 

The  New  York  Board  of  Health  reported  a  series  of  immunizing  in- 
jections in  6806  individuals,  given  by  their  inspectors  from  January  1, 
1895,  to  January  1,  1900.  Out  of  the  above  number,  18  contracted  diph- 
theria of  a  mild  type;  1  contracted  diphtheria  complicated  with  scarlet 
fever;  total,  19  cases,  the  last  case  of  scarlet  fever  ending  fatally.  The 
New  York  Board  of  Health,  Division  of  Bacteriology,  from  January,  1898, 


532  THE  INFECTIOUS  DISEASES. 

to  JsumaiTj,  1900,  reports  683  cases  of  diphtheria  which  were  secondary  to  an 
original  case  in  the  same  family.  Under  secondary  are  included  only  those 
cases  which  occurred  at  least  twenty-four  hours  after  and  within  thirty 
days  of  the  primary  case.  Of  these  682  cases,  61  died,  a  mortality  of  8.9 
per  cent.  Had  these  682  cases  received  antitoxin  (immunizing  dose)  when 
the  physician  first  visited  the  families,  probably  not  one  of  them  would 
have  contracted  the  disease.  When  immunity  is  conferred  by  an  injection 
of  antitoxin  it  lasts  about  twenty  days,  provided  it  is  given  twenty-four 
hours  p-evious  to  actual  exposure. 

As  a  rule  no  harm  will  result  by  the  injection  provided  the  serum  used 
is  of  a  standard  quality.  We  must  not  expect  to  prevent  follicular  tonsil- 
litis or  any  other  disease  by  an  immunizing  injection  of  antitoxin. 

Morrill  reports  that  of  1808  children  immunized  at  least  every  twenty- 
eight  days  with  150  to  500  units  of  serum,  7  had  diphtheria :  3  from  in- 
sufficient dosing,  2  within  twenty-four  hours  of  the  injection,  and  2  in 
twenty-two  and  twenty-three  days.  Of  829  who  had  not  been  given  anti- 
toxin, or  in  whom  more  than  twenty-eight  days  elapsed  after  the  injection, 
9  had  diphtheria,  besides  3  immunized  adults. 

Biggs  and  Guerard,  from  35  reports  of  17,516  eases  in  which  small 
doses  of  antitoxin  were  given  as  an  immunizing  agent,  state  that  diphtheria 
occurred  in  131  cases:  109  mild  cases  and  1  fatal. case  within  thirty  days 
of  the  date  of  injection;  30  mild  cases  and  1  fatal  case  after  thirty  days. 

At  the  New  York  Infant  Asylum  107  cases  of  diphtheria  occurred 
between  September  and  January,  1895  (30  cases  a  month).  In  October 
bacteriologic  examination  showed  diphtheria  bacilli  in  almost  one-half  of 
the  throats, 

January  16th  224  children  were  given  immunizing  doses  of  antitoxin, 
and  up  to  February  15th  only  1  case  of  diphtheria  occurred.  A  second  case 
then  developed  and  between  February  15th  and  27th,  5  cases.  On  the  25th 
245  children  received  antitoxin,  and  no  cases  occurred  for  thirty-one  days. 
To  sum  up :  before  isolation  and  immunization  107  cases  occurred  in  one 
hundred  and  eight  days;  after  the  latter  was  practiced,  5  cases  in  one 
hundred  and  twelve  days. 

The  occurrence  of  diphtheria  during  an  epidemic  of  measles  at  the 
iSTew  York  Foundling  Hospital  added  greatly  to  the  mortality  of  the  dis- 
ease. During  an  epidemic  of  measles  at  that  institution  every  child  was 
given  400  units  of  antitoxin.  The  result  was  most  encouraging,  as  is  shown 
by  the  immunity  conferred  by  the  injection. 

In  149  cases  of  measles,  500  units  of  diphtheria  antitoxin  were  given  at 
the  first  appearance  of  measles  symptoms.  No  cases  of  diphtheria  secondary 
to  measles  occurred  in  any  of  those  cases  for  a  period  of  one  month  at  least. 
Since  the  appearance  of  the  latter  report  another  epidemic  of  measles  has 
occurred  at  this  institution.     The  children  were  given  500  units  of  anti- 


DIPHTHERIA.  533 

toxin  each,  but  it  was  apparent  in  a  number  of  instances  that  immunity 
from  diphtheria  did  not  last  for  more  than  eighteen  days  to  three  weeks, 
at  which  time  several  cases  of  diphtheria  occurred,  complicating  or  follow- 
ing measles,  and  generally  proved  fatal.  This  relatively  shorter  period  of 
immunity  from  diphtheria  in  measles  cases  has  been  noted  in  France  and 
Germany,  and  for  this  reason  Slawyk  recommends  that  the  immunizing 
dose  be  repeated  every  two  weeks  in  measles  epidemics. 

Krauss  gives  an  extensive  analysis  of  results  of  immunizing  doses  in  122 
hospital  cases,  which  were  divided  as  follows :  44  were  scarlet  fever  cases, 
2  of  which  later  contracted  diphtheria;  31  cases  of  children  were  sent  to 
the  diphtheria  pavilion  and  found  not  to  have  true  diphtheria;  no  cases 
contracted  it;  47  measles  cases,  many  of  them  complicated;  1  developed 
diphtheria. 

Thus,  of  122  cases,  all  of  whom  were  more  or  less  exposed  to  the  dis- 
ease, and  all  ill  with  diseases  most  likely  to  be  complicated  by  diphtheria, 
only  3  became  infected,  on  the  twenty-sixth,  twenty-seventh,  and  forty-first 
day  after  inoculation.  The  dose  of  antitoxin  ranged  from  200  to  400 
units,  the  latter  being  given  to  the  children  with  suspected  diphtheria. 

Modern  Treatment  of  Diphtheria. 

The  treatment  of  diphtheria  requires  careful  consideration  in  each  and 
every  case.  Certain  conditions  must  be  met;  therefore  it  is  wise  to  look 
ahead. 

Hygienic  Treatment. — Put  the  child  to  bed  in  a  large,  airy  room. 
The  room  must  be  free  from  draught  and  so  arranged  that  proper  ventila- 
tion can  easily  be  carried  out.  Fresh  air  in  the  treatment  of  this  disease  is 
of  prime  importance.  Pseudo-membranous  deposits  in  the  nose,  pharynx, 
larynx,  or  tonsils  will  frequently  cause  a  mechanical  impediment  to  the 
entrance  of  oxygen.  Carbonic  acid  poisoning  can  easily  take  place,  and 
the  entrance  of  fresh  air  into  the  lungs  is  of  the  greatest  importance.  In 
simple  diphtheria,  or  if  we  have  an  extension  of  the  croupous  deposits  into 
the  bronchi,  perfect  oxygenation  of  the  lungs  is  demanded.  Having  given 
attention  to  proper  ventilation,  we  must  seek  to  maintain  an  equal  tempera- 
ture in  the  room.  The  temperature  of  the  sick-room  should  be  between  65° 
and  72°  F.  The  entrance  of  sunlight  is  of  prime  importance.  When  we 
consider  the  great  antiseptic  properties  of  sunshine  and  its  beneficial  effect 
upon  the  patient,  then  we  must  see  the  importance  of  admitting  as  much 
light  and  sunshine  as  possible. 

The  Bath. — Next  in  importance  to  fresh  air  and  sunlight  is  the  bath. 
Every  patient  with  diphtheria  should  be  sponged  twice  daily  with  a  tepid 
sponge  bath.  The  body  should  be  briskly  rubbed  for  a  few  minutes  after 
the  bath  to  stimulate  the  cutaneous  circulation.  By  opening  the  pores  of 
the  skin  we  naturally  favor  elimination;  hence  it  is  advisable  to  encourage 
diaphoresis  by  attending  to  the  skin. 


534 


THE  INFECTIOUS  DISEASES. 


Specific  or  Antitoxin  Treatment. 

Manner  of  Administering  the  Antitoxin. — ^The  greatest  amount  of 
care  should  be  exercised  in  administering  antitoxin.  The  skin  of  the 
patient  at  site  of  puncture  should  be  painted  with  tincture  of  iodine.  The 
physician's  hands  and  the  needle  used  should  be  rendered  aseptic.  Disin- 
fect the  sj^ringe  with  alcohol.  Abscesses  need  not  form  at  the  base  of  punc- 
ture if  care  and  attention  are  bestowed  to  strict  cleanliness. 

Part  of  the  Body  Chosen: — ^Wherever  a  loose  fold  of  skin  can  be 
pinched  up,  for  example  on  the  thigh,  the  loose  tissues  of  the  abdomen,  the 
outer  portion  of  the  chest,  or  between  the  shoulder  blades,  the  needle 
should  be  inserted  into  the  cellular  tissue  and  the  antitoxin  gradually- 
injected.  The  puncture  should  then  be  sealed  with  a  drop  of  collodion. 
Fill  the  syringe  with  antitoxin  and  expel  all  air  before  injecting  the 
patient.  Sudden  death  after  the  injection  of  antitoxin  has  been  reported 
when  this  precaution  was  neglected  and  air  was  injected  into  a  vein. 

According  to  Ehrlich,  the  diphtheria  toxin  consists  of  three  substances : 
toxoid,  toxin,  and  toxone.  The  toxoid  is  harmless;  the  toxin  is  the  cause 
of  the  acute  symptoms,  and  the  toxone  is  the  cause  of  the  late  paralysis. 
The  three  substances  are  neutralized  by  antitoxin  in  the  order  named,  so 
that  an  insufficient'  dose  of  antitoxin  may  neutralize  the  toxoid  and  toxin 
only,  thus  leaving  the  toxins  still  active  and  able  to  cause  paralysis. 

Dose  Required. — At  the  meeting  of  the  Medical  Board  of  the  Willard 
Parker  and  Riverside  Hospitals,  held  June  8,  1915,  the  committee 
appointed  to  formulate  the  dosage  and  method  of  administration  of  anti- 
toxin in  the  treatment  of  the  various  types  of  cases  of  diphtheria  in  the 
hospitals  reported  as  follows : — 

Dosage  of  Antitoxin. 


Infants — 10    to     30     pounds    in    weight 
( under  2  years  of  age )    


Children — 30    to    90    pounds    in    weight 
(under  15  years  of  age)    


Adults — 90  pounds  and  over  in  weight. 


Mild  Cases. 

Moderate. 

Severe. 

2000 

3000 

5000 

to 

to 

to 

3000 

5000 

10,000 

3000 

4000 

10,000 

to 

to 

•    to 

4000 

10,000 

15,000 

3000 

5000 

10,000 

to 

to 

to 

5000 

10,000 

20,000 

10.000 


15,000 

to 
20,000 

20,000 

to 
40,000 


It  was  decided  tliat  laryngeal  diphtheria,  moderate  cases  seen  late  at 
the  time  of  tlie  first  injection,  and  cases  of  diphtheria  occurring  as  a  com- 
plication of  the  exanthemata  sliould  be  classified  and  treated  as  "severe" 


DIPHTHERIA. 


535 


c-iisi's  ill  (his  sfluMlulc.  'iMic  <()iiiiiii(t.('('  ivfoiiiiuciKlcd  a  single  dose  in  all 
cases  of  the  proper  anion nl.  as  indicated.  The  methods  of  administration 
reconnncnded  for  mild  and  U>\'  moderate  cases  were  intramuscular  or  sub- 
cutaneous; for  severe  eases  intraiiiuscular.  subcutaneous  or  intravenous;  for 
ma.lio-nant  cases  intravenous. 

Tlic  dose  of  antitoxin  for  immunizing  purposes  was  fixed  at  1000  units. 

Severe  Cases. — When  we  are  dealing  with  a  severe  toxaemia  with  marked 
general  depression  and  large  masses  of  pseudo-membranes  in  the  throat, 


190*- 

DATES  OF  OBSERVATIONS    | 

^<K 

15 

16 

17 

18 

19 

Cent. 

Fahr. 

AMiPM 

AM.'PM 

AM 

:pm 

am:pm 

AMiPM 

39°" 

38'~ 
37  ~ 

•8 

•6 

-103° -2 

\ 

•8 

-102°- 2 

\ 

\ 

•8 
-         -6 

-101°' 2 

;\ 

\ 

L         -8 
•6 

-100° -2 

\ 

•8 
•6 

-99° -2 

:' 

•  8 
-        -6 

i 

'^S 

<  • 

/formal 

86  ~ 

,-.'.,       '         ^ 

-98°-2 

\/^ 

•  8 

•  6 

-97°-2 

360c 

Unit 

'  in,it 

cM 

•  8 

•  6 
-      o  •  4 

-96  -2 

1 

•';/ 

Pulse 
per  minute 

S4 

«5 

0 

0 

s§ 

Besplrations 
per  minute 

«s4 

SJ 

Fig.  1G7. — Temperature  Chart  from  a  Case  of  Diphtheria,  showing  the 
Specific  Effect  of  Antitoxin  on  the  Temperature.  Note  also  the  effect  on 
the  pulse.     (Original.) 


then  at  least  10,000  units  of  antitoxin^  should  be  injected  in  the  beginning. 
When  the  cervical  lymph  glands  are  enlarged  and  there  is  slight  or  severe 
evidence  of  stenosis,  then  at  least  10,000  units  should  be  injected  in  the 
beginning. 


^It  is  frequently  necessary  to  repeat  the  dose,  so  that  10,000  units  may  be 
given  during  the  first  day  of  illness,  if  no  improvement  is  noted.  The  dose  of  10,000 
units  may  be  repeated  during  the  first  three  days  if  no  improvement  is  noted.  I  am 
in  favor  of  large  doses  and  watch  the  child's  condition  as  the  guide  when  suflBcient 
antitoxin  has  been  injected. 


536 


THE  INFECTIOUS  DISEASES. 


Indications  for  a  Second  and  Third  Injection. — ISTo  positive  rule  can 
be  made  that  will  apply  to  all  cases  of  diphtheria.  While  it  may  be  wrong 
theoretically  to  give  a  second  or  third  injection  of  antitoxin,  I  have  seen 
cases  where,  even  though  a  large  injection  was  given  at  the  beginning  of 
the  disease,  it  required  a  second  and  a  third  dose  to  stimulate  the  previous 
dose  to  activity.  Thus  my  advise  is  to  give  a  large  dose  at  the  beginning, 
but  do  not  be  afraid  to  repeat  the  dose  after  t^venty-four  hours  if  no  objec- 
tive improvement  is  noted. 

Effect,  of  Antitoxin  on  the  Blood.- — It  has  been  found  experimentally 
by  Dr.  Park  that  if  an  injection  of  10,000  units  was  given  to  children  a 
second  injection  rarely  was  necessary.'   The  antitoxin  was  found  to  reach 


Fig.  168. — No.  1  shows  the  method  of  transfixing  and  raising  the  vein 
with  a  sewing-needle  and  holding  it  in  the  elevated  position  by  means  of  a 
haemostat.  The  syringe  needle  is  shown  inserted  into  the  vein  beneath  the 
transfixing  needle.  No.  2  shows  more  in  detail  the  method  of  fixation  and 
the  insertion  of  the  needle.  No.  3  shows  what  frequently  happens  in  at- 
tempting to  insert  the  needle  of  the  syringe  without  first  fixing  the  vein. 
(After  Watson. y 

the  blood-stream  slowly,  increasing  up  to  the  third,  fourth,  or  fifth  day, 
and  then  slowly  decreasing.  That  if  the  second  dose  were  given  twelve 
hours  after  the  first  the  beneficial  effects  which  might  be  attributed  to  it 
were  really  due  to  the  continued  absorption  of  the  first  dose,  the  second  only 
contributing  its  share.  It  was  also  found  that  when  antitoxin  was  given 
intravenously  a  large  amount  of  it  went  into  the  blood-stream  immediately ; 
therefore,  this  means  should  be  used  in  desperate  cases. 

Intravenous  Injections. — The  most  rapid  method  of  bringing  the  anti- 
toxin into  direct  contact  with  the  toxin  is  by  intravenous  injection.  The 
dose  injected  should  be  at  least  10,000  to  20,000  units.     The  site  of  the 


DIPHTHERIA.  537 

injection  preferred  is  the  median  basilic  vein  at  the  bend  of  the  elbow.  In 
very  young  infants  the  jugular  vein  is  more  preferable.  With  a  supporting 
pillow  at  the  nape  of  the  neck  the  jugular  vein  stands  out  prominently  and 
the  technique  of  the  injection  is  simplified.  In  many  instances  it  will  be 
necessary  to  expose  the  vein  in  order  to  successfully  inject  the  antitoxin. 
With  the  aid  of  a  6  per  cent,  aqueous  cocaine  solution  local  anaesthesia  can 
be  sufficiently  attained.  If  we  are  careful  to  exclude  all  air  while  injecting 
the  antitoxin^  no  untoward  symptoms  will  follow.  If  the  site  of  the 
median  basilic  vein  is  chosen,  compression  above  the  bend  of  the  elbow  will 
make  the  vein  stand  out  prominently.  Sterilize  the  surface,  and  inject 
several  drops  of  cocaine.  Make  a  small  incision  across  the  course  of  the 
vein. 

The  arm  is  corded  above  the  elbow,  so  as  to  cause  the  vein  to  become 
distended  and  prominent.  The  vein  is  then  transfixed  with  a  straight 
surgical  needle.  The  cord  may  then  be  loosened  and  the  needle  of  the 
syringe  inserted  into  the  vein  at  right  angles  to  and  beneath  the  surgical 
needle,  which  is  raised  by  a  haemostatic  forceps.  Fig.  168  illustrates  the 
advantages  of  this  method. 

Laryngeal  Stenosis. — It  is  always  a  safe  plan  to  give  an  injection  of 
5000  units;  and  if  the  stenosis  does  not  disappear  in  twelve  hours,  I  give 
an  additional  injection  of  5000  units,  so  that,  in  all,  10,000  units  may  be 
injected  during  the  first  twenty-four  hours  (read  article  on  "Intubation"). 

The  above  treatment  with  antitoxin  will  be  serviceable  when  we  are 
dealing  with  a  pure  Klebs-Loeffler  infection,  but  there  are  a  great  many 
cases  in  which  we  have  a  mixed  infection,  and  the  streptococcus  infection 
predomJnates, 

There  are  contributing  factors  frequently  leading  to  a  fatal  termination. 
First  and  foremost  is  the  presence  of  the  streptococcus  in  addition  to  the 
Klebs-Loeffler  infection.  In  these  mixed  infections  we  have,  in  addition  to 
the  general  diphtheria,  a  distinct  streptococcemia.  In  these  cases  antitoxin 
is  inert  as  regards  the  streptococcus.  We  frequently  have  broncho-pneu- 
monia, nephritis,  arthritis,  otitis,  and  local  abscesses  due  to  the  invasion  of 
the  streptococcus.  To  neutralize  such  mixed  infection  we  require  besides 
the  Klebs-Loeffler  antitoxin  a  streptococcus  antitoxin  or  a  potent  antistrep- 
tocoecus  serum. 

The  bacteriological  findings  will  therefore  be  the  guide  in  the  future  in 
determining,  first,  luhether  a  culture  from  the  throat  shows  a  mixed  or  an 
unmixed  infection  and  in  addition  to  this  bacteriological  examination,  the 
blood  must  be  examined  to  determine  the  presence  or  absence  of  a  strepto- 
coccemia. The  treatment  must  be  based  on  scientific  data;  hence  it  should 
conform  with  the  result  of  what  is  found  by  culture  from  the  throat  and  by 
the  thorough  examination  of  the  blood. 

Jf  we  can  inject  a  sufficient  quantity  of  antitoxin  to  stimulate  cell 


538  THE  LNFECTIOUS  DISEASES. 

activity  and  neutralize  general  toxsemia,^  then  we  give  our  patient  tlie  great- 
est opportunity  to  eliminate  this  deadly  poison  and  to  begin  convalescence. 

The  presence  of  pseudomembranes  filled  \nih.  Klebs-LofHer  bacilli  is 
a  source  of  great  danger.  This  danger  consists  in  the  liberation  of  the 
toxins  and  the  producing  of  a  profound  systemic  infection.  The  longer 
the  membranes  remain  the  more  systemic  poisoning  will  take  place.  This 
poison  will  inhibit  the  functions  of  the  heart,  of  the  kidneys,  and  of  the 
other  vital  organs  of  the  body.  Persistent  membranes  should,  therefore, 
be  regarded  as  of  grave  prognostic  omen,  and  therapeutic  measures  should 
be  directed  towards  exfoliating  these  membranes  as  rapidly  as  possible. 

In  the  early  stages  of  diphtheria  we  do  not  encounter  this  toxaemia, 
but  when  the  membranes  remain,  the  toxins  liberated  by  the  pathogenic 
micro-organisms  give  a  systemic  poisoning  ending  in  a  toxic  myocarditis 
or  a  toxic  nej)hritis.  It  is  important,  therefore,  to  use  vigorous  treatment 
earh",  and  correct  thereby,  if  possible,  the  tendency  to  a  general  toxaemia. 

The  toxic  effect  is  noticeable  on  the  nervous  system.  Such  children 
are  peevish  and  irritable  by  day  and  restless  at  night.  The  constant 
absorption  of  toxins  from  necrotic  pseudomembranes  located  in  the  rhino- 
pharynx,  larynx,  or  trachea,  destroys  the  muscular  energ}"  and  saturates 
and  poisons  the  central  nervous  system.  These  are  the  immediate  symp- 
toms seen  during  the  earl}^  stages  of  the  diphtheritic  infection,  ^^^len, 
however,  this  toxin  is  permitted  to  accumulate  in  the  S3'stem  it  frequently 
causes  permanent  paralysis.  This  paralysis  usually  involves  the  lower 
extremities  in  the  form  of  a  multiple  neuritis.  Another  danger  consists  in 
swallowing  the  pseudomembrane,  and  thereby  infecting  the  stomach. 

The  ordinary  shortcomings  that  are  most  frequently  met  with  consist 
of  placing  too  much  reliance  on  the  specific  nature  of  antitoxin  regardless 
of  other  vital  necessities.  In  this  infectious  disease,  where  there  is  marTced 
leucocytosis  and  other  evidences  of  subnormal  hcemic  conditions,  the  indi- 
cation next  to  antitoxin  is  for  restorative  treatment,  especially  nutrition. 

Dietetic  Treatment. — As  a  tissue  and  blood  builder  no  medication 
equals  food.  It  is,  therefore,  imperative  to  support  the  general  nutrition  by 
proper  feeding.  Milk  diluted  with  some  cereal  decoction,  like  oatmeal,  bar- 
ley or  rice,  will  be  better  borne  than  pure  milk  alone.  Buttermilk  or  zoolak 
may  be  given.  Sometimes  it  is  necessary  to  partially  peptonize  milk  to 
render  it  more  absorbable.  If  the  child  is  old  enough  the  yolk  of  a  raw  egg 
can  be  added  to  the  milk  (egg-nog).  Concentrated  beef  broth,  chicken 
broth,  clam  broth  or  oyster  broth  should  be  thought  of.  When  feeding  once 
in  three  hours,  it  is  a  good  plan  to  give  some  of  this  concentrated  broth,  fol- 
lowed in  three  hours  by  a  milk  feeding,  and  so  alternate.  In  this  manner 
we  give  our  patient  milk  once  in  six  hours.    Acid  fruits,  such  as  oranges, 

*In  septic  diphtheria  where  profound  toxsemia  exists  an  intravenous  injection 
of  10,000  to  20,000  units  of  antitoxin  should  be  used. 


DIPHTHERIA.  539 

lemons,  grapes,  and  cranberries,  are  very  well  borne.  When  acid  fruits  are 
ordered  they  should  be  given  an  hour  before  milk  feeding.  Older  children 
can  be  given  raw  scraped  steak,  calf's-foot  jelly,  and  ice  cream,  which  is 
nutritious  and  pleasant.  When  it  is  difficult  to  feed  hy  mouth  owing  to 
excessive  vomiting  or  to  anorexia,  or  where  intubation  has  been  performed, 
it  is  a  good  plan  to  let  the  stomach  have  absolute  rest  and  to  depend  on : — 
Rectal  Feeding. — No  more  than  two  ounces  should  be  injected  at  one 
time. 

Milk,  predigested  1  ounce 

Starch    water    1  ounce 

Laudanum , 1  minim 

To  be  injected  slowly  through  a  colon  tube  after  both  colon  and  rectum  have 
been  cleansed  by  a  soap-suds  enema. 

If  the  small  nutritive  enema  is  well  retained  we  can  repeat  the  injection 
once  every  four  hours,  and  add  the  yolk  of  a  raw  egg  to  the  above  formula 
of  milk,  starch,  and  opium.  Next  in  importance  to  giving  the  proper  dose 
of  antitoxin  is  the  nutrition  of  the  body,  which  has  just  been  considered. 

Elimination  of  Toxins. — The  elimination  of  toxic  elements  can  only 
take  place  by  means  of  the  bowels,  kidneys,  and  skin.  Normally  in  febrile 
conditions  there  is  a  general  torpidity  of  the  emunctories.  Thus  it  is  ap- 
parent that  a  dose  of  calomel,  citrate  of  magnesia,  or  an  alkaline  solution, 
like  the  milk  of  magnesia  or  a  laxative  mineral  water,  will  aid  in  the  per- 
formance of  these  functions. 

Medicinal  Treatment. — It  is  advisable  to  remove  the  putrid  membranes 
from  the  nose  and  throat  and  also  the  catarrhal  discharges.  To  do  this, 
mechanical  treatment  consisting  of  the  cleansing  of  the  nose  with  a  salt 
solution  of  the  strength  of  one  dram  of  table  salt  to  one  pint  of  water  is 
useful.  A  weak  (%  per  cent.)  solution  of  permanganate  of  potash  can  also 
be  used  to  cleanse  the  nose  with  the  aid  of  a  syringe  (see  Fig.  200). 

Septic  products  in  the  nose  and  throat  will  frequently  lead  to  a  fatal 
termination.  Their  presence  is  a  constant  menace  to  the  blood  by  inviting 
toxaemia.  In  addition  thereto  they  give  rise  to  fever  and  not  infrequently 
septic  material  will  find  its  way  from  the  nose  and  pharynx  into  the 
Eustachian  tubes,  causing  abscesses.  If  neglected  it  may  lead  to  mastoid 
involvement  and  brain  abscesses  or  to  septic  meningitis,  with  little  or  no 
chance  of  recovery. 

By  observing  the  enlarged  lymph  glands,  it  is  surprising  to  see  what 
good  result  is  apparent  after  cleansing  the  nose  and  pharynx. 

Local  Treatment  of  the  Pseudo-memlranes. — The  solvent  effect  of  local 
remedies  I  have  never  been  able  to  see.  When  papayotin  has  been  used,  I 
have  been  disappointed  in  its  effect.  Creosote  vapor,  by  adding  a  dram  of 
beechwood  creosote  to  a  pint  of  water  and  allowing  the  air  to  become  im- 
pregnated with  the  vapor,  has  shown  some  good  in  a  few  instances.    Lugol's 


540  "  THE  INFECTIOUS  DISEASES. 

solution  of  iodine  (half -strength),  applied^ by  means  of  absorbent  cotton,  can 
be  recommended,  A  steam  atomizer  containing  a  weak  solution  of  2  per 
cent,  sulphurous  acid  is  sometimes  of  value.  The  latter  has  been  used  by 
me  and  certainly  can  be  recommended  when  there  are  extensive  necrotic 
patches.    It  is  far  better  than  peroxide  of  hydrogen. 

Enlarged  Lymph  Glands. — Other  local  treatment  which  I  have  used 
with  benefit  is  the  inunction  of  unguentum  Crede  into  the  cervical  glands, 
rubbed  in  at  least  fifteen  to  twenty  minutes  two  or  three  times  a  day.  An 
ice-bag  worn  continually  can  also  be  recommended  when  there  is  an  extensive 
oedema.  Some  cases  do  better  by  the  application  of  a  warm  flaxseed  poultice 
covered  with  oil-silk,  or  by  the  application  of  a  hot-water  bag. 

Oxygen  is  indicated  and  required  when  there  is  the  slightest  evidence 
of  cyanosis.  It  will  also  relieve  dyspnoea  when  present.  It  is  especially  indi- 
cated during  broncho-pneumonia,  which  so  often  complicates  diphtheria. 

Fever  Treatment. — It  is  a  wise  plan  to  exclude  antipyretic  drugs  during 
the  treatment  of  fever  in  diphtheria.  The  best  antipyretic  measures  con- 
sist in  sponging  with  evaporating  lotions  such  as  alcohol  and  water  or  acetic 
ether,  locally.  Cold  packs  and  flushing  the  bowel  with  cold  water  are  very 
serviceable  in  some  cases.  When  high  fever  due  to  pneumonia,  to  nephritis 
or  to  any  other  complication  exists,  the  same  should  be  treated  as  though  the 
disease  existed  independent  of  the  diphtheria. 

When  fever  exists  and  the  child  cries  continuously  then  the  ears 
should  be  examined.  Frequently  an  otitis  media  will  keep  up  high  fever 
until  the  drum  is  punctured.  Ten-  to  20-  drop  doses  of  sweet  spirit  of  niter 
are  valuable  if  given  several  times  a  day.  During  the  febrile  stage  of 
diphtheria,  calomel  in  ^/^o-  to  %-  grain  doses,  repeated  several  times  a  day, 
is  a  useful  adjuvant  in  fever  treatment. 

Stimulation. — Owing  to  the  depressing  effect  of  the  diphtheritic 
poisons,  stimulation  should  begin  early.  Strychnine,  ^Aoo  grain,  for  a  child 
1  year  old,  repeated  three  or  four  times  a  day,  may  be  given.  The  dose  can 
be  gradually  and  cautiously  increased  until  a  systemic  effect  is  noticeable. 
Children  will  tolerate  very  large  doses  of  strychnine  just  as  they  will  tolerate 
very  large  doses  of  whisky.  They  can  be  combined.  Tokay  wine,  cham- 
pagne and  coffee  are  valuable  cardiac  stimulants.  Caffeine  citrate  and 
sparteine '  are  also  serviceable  for  enfeebled  heart's  action.  The  prognosis 
of  a  case  of  diphtheria  is  certainly  better  in  a  case  where  the  heart  has  been 
supported  until  the  toxgemia  has  passed  away. 

Paralysis. — The  internal  treatment  of  paralysis  consists  of  strychnine 
and  the  usual  restorative  treatment.  Galvanic  and  faradic  electricity  are 
good.    Absolute  rest  in  bed  and  gentle  massage  are  indicated. 

Statistics  of  the  Kaiser  and  Kaiserin  Friedrich  Hospital  in  Berlin 
show  a  very  interesting  comparison  between  the  mortality  before  and  after 
antitoxin  was  used. 


CHRONIC  DIPHTHERIA.  541 

The  death  rate  was  36.56,  35.57,  and  45.78  in  three  successive  years, 
or  an  average  of  39.63  per  cent.  In  the  year  1894,  when  the  serum  treat- 
ment was  first  used,  although  experimentally,  there  were  two  interesting 
♦data:  first,  the  mortality  among  cases  treated  with  antitoxin  was  16.6  per 
cent.;  second,  those  treated  without  antitoxin,  mortality  27.8  per  cent. 
In  the  following  year  (1895)  all  cases  of  diphtheria  were  injected  with 
antitoxin;  the  mortality  fell  to  11.2  per  cent. 

Immunity. — Four  hundred  and  sixty  children  were  injected  with  the 
object  of  producing  immunity.  Of  these  only  18  came  down  with  diph- 
theria.   All  of  these  cases  were  mild  and  not  one  died. 

A  comparative  study  of  the  deaths  before  antitoxin  was  used  and  the 
present  method  of  treatment,  where  all  cases  receive  antitoxin,  can  hardly 
be  made.  I  frequently  see  septic  cases  sent  to  the  hospital  in  a  moribund 
condition.  The  city  hospital  is  used  as  a  dumping  ground  for  all  malignant 
cases;  hence  the  high  mortality  rate.  The  cases  admitted  belong  to  the 
laboring  class  of  people.  As  these  people  are  very  poor,  they  delay  sending 
for  a  physician  until  severe  laryngeal  stenosis  sets  in.  When  the  disease 
has  gained  headway  and  there  is  a  general  septic  condition,  recovery,  as  a 
rule,  is  doubtful. 

Chronic  Diphtheria. 

There  are  two  varieties  which  characterize  this  condition : — 

The  first  form  is  simply  the  continuation  of  an  acute  attack  of 
diphtheria,  running  a  prolonged  course.  Second,  a  chronic  form  in  which 
symptoms  of  pseudo-membranous  rhinitis  exist  and  which  may  be  present 
months  or  years. 

In  the  prolonged  type  previously  mentioned,  fever,  glandular  swelling 
and  general  systemic  disturbances  mark  the  beginning  of  the  attack.  In 
the  latter  type  the  febrile  manifestations  and  general  constitutional  dis- 
turbances are  totally  absent. 

Diagnosis. — The  clinical  picture  of  the  chronic  type  of  diphtheria 
narrows  down  to  two  distinct  features :  First,  the  presence  of  pseudo-mem- 
branes in  the  nose,  pharjux,  or  larynx  for  months  or  years.  Second,  the 
persistence  of  the  Klebs-LoefSer  bacillus.  Third,  the  marked  absence  of 
general  constitutional  disturbances. 

Neisser,  v.  Behring,  Walb,  and  more  recently  Newfield  describe  this 
form  of  diphtheria.  He  foimd  that  a  series  of  cases  of  rhinitis  atrophicans 
and  ozjBna  showed  Klebs-Loeffler  bacillus  in  addition  to  the  ozjena  bacillus. 
I  have  met  with  cases  of  this  prolonged  type  of  diphtheria  which  clinically 
resembled  syphilis. 

Prognosis  and  Course. — Such  cases  require  very  careful  observation  and 
a  very  guarded  opinion  should  be  expressed  as  to  the  length  of  time  that 
the  condition  will  last.     Not  infrequently  tuberculosis  or  some  form  of 


542  THE  INFECTIOUS  DISEASES. 

chronic  broncho-piieumoiiia  may  follow  with  fatal  result.  In  a  case  of 
chronic  diphtheria  extending  over  seven  months  which  was  complicated 
by  entero-colitis  during  midsummer,  the  result  was  fatal. 

Isolation. — The  presence  of  the  Klebs-Loeffler  bacillus  demands  the 
strictest  isolation  from  all  healthy  persons.  The  virulent  nature  of  the 
LoeflBer  bacillus  should  be  remembered.  All  children  suffering  with  en- 
larged tonsils  or  those  having  adenoid  vegetations  should  be  carefully 
guarded  against  exposure  to  a  case  of  this  kind,  as  they  are  more  prone 
to  infection  than  those  having  healthy  throats. 

Treatment. — If  we  are  dealing  with  a  subnormal  condition,  the  system 
must  be  built  up  with  codliver-oil  in  addition  to  a  concentrated  diet,  such  as 
eggs,  cereals,  and  broths.  The  most  valuable  drug,  undoubtedly,  is  iron. 
The  tincture  of  the  chloride  of  iron,  10  to  30  drops,  three  times  a  day,  or 
oftener,  is  very  useful  for  its  local  as  well  as  its  systemic  effect.  I  administer 
iron,  regardless  of  its  constipating  tendency,  for  weeks  and  months. 

Locally,  a  bichloride  spray  or  a  spray  of  Dobell's  solution  can  be  used 
three  or  four  times  a  day.  If  after  several  weeks  of  persistent  treatment 
no  benefit  results,  then  a  decided  change  of  air,  such  as  a  trip  to  the  seashore 
or  to  the  mountains,  will  assist  in  the  cure  of  the  patient. 

Intubation". 

When  lar}Tigeal  stenosis  occurs  during  a  case  of  diphtheria,  then  we 
must  prepare  for  intubation. 

The  following  symptoms  demand  intubation : — 

Labored  breathing. 

A  gradual  and  progressive  dyspnaa. 

A  failing  or  intermittent  pulse. 

Cyanosis  showing  defective  oxygenation. 

Eetraction  of  chest  wall  most  marked  at  epigastrium  or  at  the  clavicles. 

When  the  accessory  muscles  of  respiration  are  brought  into  play. 

When  the  child  is  compelled  to  sit  upright  in  order  to  breathe  and 
pulls  at  its  neck  and  throws  itself  from  side  to  gide,  gasping  for  breath. 

The  management  of  a  case  of  intubation  in  private  practice  should  be 
carefully  considered.  No  child  should  be  permitted  to  wear  a  tube  in  the 
lar}Tix  without  the  constant  supervision  of  a  trained  nurse.  In  the  Willard 
Parker  Hospital  we  have  competent  trained  nurses  both  night  and  day,  and 
a  physician  is  always  ready  to  respond  in  case  of  emergency.  I  have  fre- 
quently intubated  in  private  practice  and  always  give  the  following  orders 
to  the  trained  nurse : — 

First. — If  the  breathing  becomes  labored  or  if  the  child  has  a  sudden 
increase  in  the  number  of  respirations,  notify  the  physician  at  once. 

Second. — Watch  the  pulse;  a  sudden  increase  in  the  pulse-rate  or  a 
sudden,  intermittent  pulse  means  danger. 


INTUBATION. 
Table  No.  55. — Diphtheria  Cases — Willard  Parker  Hospital. 


543 


Year. 

No.  Treated. 

Died. 

Mortality 
Per  cent. 

Eecov  ries 
Per  cent. 

Intubations. 

Recover- 
ies 
Inclusive. 

Recoveries 
Per  cent. 

1901 

919 

275 

29.92 

70.08 

222 

70 

31.53 

1902 

1112 

271 

24.37 

75.63 

258 

116 

44.92 

1903 

1281 

356 

27.79 

72.21 

352 

123 

.34.94 

1904 

1402 

356 

25.39 

74-61 

410 

193 

47. 

*1905 

478 

98 

20.50 

79.50 

154 

86 

56. 

Total 

5192 

1356 

26.12 

73.88 

1396 

588 

43.13 

*0n  account  of  rebuilding  tlie  Hospital,  no  patients  were  received  after  June  17th. 

Third. — If  cyanosis  or  sudden  apncea  occurs,  possibly  caused  by  a 
plugging  of  the  lower  portion  of  the  tube  with  membrane,  notify  the  physi- 
cian so  that  the  tube  can  be  extubated  and  a  tube  of  larger  caliber  inserted. 

Fourth. — If  the  tube  is  suddenly  expelled  during  a  paroxysm  of  cough- 
ing (auto-extubation),  a  hurry  call  should  be  sent  to  the  physician. 

What  to  Do  in  an  Emergency. — First. — Give  a  mustard  foot-bath  or 
apply  a  mustard  plaster  over  the  heart  to  stimulate  the  circulation. 

Second. — Give  5  to  10  drops  of  aromatic  spirits  of  ammonia  with  an 
equal  quantity  of  whisky.  Nitroglycerine  can  be  given  in  ^/loo-gi'ain  doses 
every  hour,  hypodermically  if  necessary. 

Third. — Eelieve  the  stenosis,  if  it  exists,  by  careful  intubation. 

Fourth. — If  an  expert  intubator  is  not  at  hand,  or  if  intubation  pushes 
membrane  downward  so  that  the  stenosis  persists,  resort  to  tracJieotomy. 

Regarding  extubation,  my  rule  in  private  practice  is  to  extubate  on  the 
fifth'  day,  or  on  the  morning  of  the  sixth  day,  provided  the  temperature  is 
normal  and  no  complication  exists.  It  is  safer  to  leave  a  tube  in  the  larynx 
one  .day  longer  than  risk  the  necessity  of  reintudation. 

My  two  principal  rules  in  intubation  and  extubation  are:  First,  avoid 
force,  thereby  avoiding  injury.  This  rule  has  been  my  greatest  aid  in 
preventing  retained  tubes.  Second,  do  not  hurry.  While  in  a  severe  laryn- 
geal stenosis  a  given  amount  of  haste  is  necessary  in  selecting  the  proper- 
sized  tube  and  making  preparations,  when  it  comes  to  the  introduction  of 
the  tube,  the  inflammatory  process  and  subnormal  condition  must  be  remem- 
bered; hence,  go  slow. 

The  nervous,  frightened  child  must  be  quieted,  especially  when  con- 
sidering extubation.  I  usually  order  an  antispasmodic  for  twelve  hours  pre- 
ceding the  removal  of  the  tube.     Codeine,  14  grain  or  ^/^  grain  to  a  child 


546 


THE  INFECTIOUS  DISEASES. 


pressure,  the  air  being  prevented  from  entering  with  sufficient  rapidity  to  fill 
the  partial  vacuum  below.  It  is  readih^  detected  in  adults,  but  not  so 
in  children,  owing  to  deeper  situation  of  the  larjaix  in  the  latter. 

"This  symptom  is  not  present  in  stenosis  of  the  trachea,  owing  to  the 


Fisf.    172.— Extubator 


great  elasticity  of  this  tube,  which  permits  of  considerable  motion  on  itself 
without  displacing  the  lar}mx. 

"Abiding  cyanosis  is  too  late  a  sjmiptom  to  wait  for,  and,  besides,  it  is 
uncertain,  as  fatal  obstruction  may  exist  in  the  glottis  with  extreme  pallor 


Fig.    173. — Built-up  Tubes  for  Granulation  Tissue.     Useful  for 
treatment  of  "retained  tubes." 

on  the  surface.  This  pallor  of  asphyxia  is  produced  by  the  excessive 
quantity  of  blood  drawn  into  and  stored  in  the  lungs  by  the  cupping-glass 
action  of  inspiration  when  the  air  is  almost  excluded.  The  blood  in  the 
cutaneous  capillaries  is  thus  reduced  to  a  minimum,  and  this,  although 
highly  charged  with  carbonic  acid,  only  serves  to  increase  the  paleness,  on 
the  principle  that  the  addition  of  a  little  blue  makes  a  clearer  white. 


INTUBATION.  547 

"The  temporary  cyanosis  which  comes  and  goes  with  the  paroxysmal 
dyspnoea  of  the  second  stage  of  croup  is  of  no  particular  significance. 
Children  seldom  remain  long  in  one  position  when  suffering  severely  from 
want  of  breath,  and  continued  restlessness,  if  consciousness  he  unimpaired, 
is  therefore  an  important  indication  that  it  is  time  to  afford  relief. 

"As  far  as  the  necessity  for  intubation  is  concerned,  it  matters  little 
as  to  the  real  nature  of  the  obstruction,  provided  it  be  in  the  larynx  and  not 
a  foreign  body.  It  may  be  croup,  simple  laryngitis,  oedema  of  the  glottis, 
paralysis,  spasm,  or  even  a  neoplasm.  In  the  latter  it  will  tide  over  the 
immediate  danger  of  asphyxia,  and  leave  more  breathing  room  to  facilitate 
the  radical  operation." 

Dorsal  Method  of  Intubation. — This  method  is  the  most  convenient,  as 
it  does  away  with  the  necessity  of  several  assistants.    I  have  frequently  in- 


Fig.  174.^ — The  Mummy  Bandage,  showing  child  in  proper  position  for 
the  dorsal  method  of  Intubation.  All  instruments  required  are  carefully 
arranged.      (Original.) 

tubated  in  the  dorsal  position  without  any  assistant.  This  method  appeals 
to  me  as  very  valuable  in  emergencies,  especially  so  when  a  physician  is 
called  out  of  town  where  no  trained  assistant  is  available.  The  method  of 
introducing  the  tube  is  the  same  as  that  described  as  the  O'Dwyer  method. 
The  dorsal  method  has  been  advocated  by  the  attending  and  resident  staff 
at  the  Willard  Parker  Hospital  and  is  the  method  employed  there  now. 

The  gag  should  be  inserted  into  the  left  side  of  the  mouth,  and  slowly 
opened.  The  trained  nurse  steadies  the  child's  head  and  holds  the  gag  in 
place.  With  the  child  flat  on  its  back,  the  hands  firmly  held  by  a  blanket 
encircling  the  body,  the  physician  stands  on  the  right  side  of  the  child  and 
introduces  the  index  finger  of  his  left  hand  in  the  median  line  until  the 
epiglottis  is  felt.  The  epiglottis  should  be  raised  and  fixed.  The  tube 
should  then  be  guided  with  the  right  hand  of  the  operator,  along  the  left 


^.The  set  of  photographs  illustrating  intubation,  extubation,  and  gavage  were 
taken  in  the  wards  of  the  Willard  Parker  Hospital. 


546 


THE  INFECTIOUS  DISEASES. 


pressure,  the  air  being  prevented  from  entering  with  sufficient  rapidity  to  fill 
the  partial  vacuum  below.  It  is  readih^  detected  in  adults,  but  not  so 
in  children,  owing  to  deeper  situation  of  the  larj^nx  in  the  latter, 

"This  S3'mptom  is  not  present  in  stenosis  of  the  trachea,  owing  to  the 


great  elasticity  of  this  tube,  which  permits  of  considerable  motion  on  itself 
without  displacing  the  larj'^nx. 

"Abiding  cyanosis  is  too  late  a  symptom  to  wait  for,  and,  besides,  it  is 
uncertain,  as  fatal  obstruction  may  exist  in  the  glottis  with  extreme  pallor 


Fig.    173. — Built-up  Tubes  for  Granulation  Tissue.     Useful  for 
treatment  of  "retained  tubes." 

on  the  surface.  This  pallor  of  asphyxia  is  produced  by  the  excessive 
quantity  of  blood  drawn  into  and  stored  in  the  lungs  by  the  cupping-glass 
action  of  inspiration  when  the  air  is  almost  excluded.  The  blood  in  the 
cutaneous  capillaries  is  thus  reduced  to  a  minimum,  and  this,  although 
highly  charged  with  carbonic  acid,  only  serves  to  increase  the  paleness,  on 
the  principle  that  the  addition  of  a  little  blue  makes  a  clearer  white. 


INTUBATION.  547 

"The  temporaty  cyanosis  which  comes  and  goes  with  the  paroxysmal 
dyspnoea  of  the  second  stage  of  croup  is  of  no  particular  significance. 
Children  seldom  remain  long  in  one  position  when  suffering  severely  from 
want  of  breath,  and  continued  restlessness,  if  consciousness  he  unimpaired, 
is  therefore  an  important  indication  that  it  is  time  to  afford  relief. 

"As  far  as  the  necessity  for  intubation  is  concerned,  it  matters  little 
as  to  the  real  nature  of  the  obstruction,  provided  it  be  in  the  larynx  and  not 
a  foreign  body.  It  may  be  croup,  simple  laryngitis,  oedema  of  the  glottis, 
paralysis,  spasm,  or  even  a  neoplasm.  In  the  latter  it  will  tide  over  the 
immediate  danger  of  asphyxia,  and  leave  more  breathing  room  to  facilitate 
the  radical  operation." 

Dorsal  Method  of  Intubation. — This  method  is  the  most  convenient,  as 
it  does  away  with  the  necessity  of  several  assistants.     I  have  frequently  in- 


Fig.  174.' — The  Mummy  Bandage,  showing  cliild  in  proper  position  for 
the  dorsal  method  of  Intubation.  All  instruments  required  are  carefully 
arranged.      (Original.) 

tubated  in  the  dorsal  position  without  any  assistant.  This  method  appeals 
to  me  as  very  valuable  in  emergencies,  especially  so  when  a  physician  is 
called  out  of  town  where  no  trained  assistant  is  available.  The  method  of 
introducing  the  tube  is  the  same  as  that  described  as  the  O'Dwyer  method. 
The  dorsal  method  has  been  advocated  by  the  attending  and  resident  staff 
at  the  Willard  Parker  Hospital  and  is  the  method  employed  there  now. 

The  gag  should  be  inserted  into  the  left  side  of  the  mouth,  and  slowly 
opened.  The  trained  nurse  steadies  the  child's  head  and  holds  the  gag  in 
place.  With  the  child  flat  on  its  back,  the  hands  firmly  held  by  a  blanket 
encircling  the  body,  the  physician  stands  on  the  right  side  of  the  child  and 
introduces  the  index  finger  of  his  left  hand  in  the  median  line  imtil  the 
epiglottis  is  felt.  The  epiglottis  should  be  raised  and  fixed.  The  tube 
should  then  be  guided  with  the  right  hand  of  the  operator,  along  the  left 


VThe  set  of  photographs  illustrating  intubation,  extubation,  and  gavage  were 
taken  in  the  wards  of  the  Willard  Parker  Hospital. 


548 


THE  INFECTIOUS  DISEASES. 


index  finger,  and  inserted  into  the  cnl-de-sac  of  the  larynx.  It  would  be 
profitable  to  read  O'Dwyer's  description  of  the  method  of  intubation  which 
I  append  here,  the  only  difference  being  that  O'Dwyer  recommends  the  sit- 
ting position,  whereas  I  advocate  the  dorsal  position. 

Upright  Method  of  Operating. — "The  nurse  or  person  who  holds  the 
child  should  be  seated  on  a  solid  chair  with  a  low  back,  and  the  patient 


'Wm*  1^ 


Fig.    175. — Intubation.     Left  index  finger  raising  the  epiglottis.     The  intro- 
ducer with  tube  attached  is  glided  along  the  finger.      (Original.) 


placed  on  the  lap  with  head  resting  on  left  shoulder  of  nurse  in  order  to 
leave  the  gag  free.  The  hands  can  either  be  held  or,  still  better,  secured  by 
the  sides,  by  a  towel  or  sheet  passed  around  the  body  and  left  in  that 
position  until  the  tube  is  inserted  and  the  string  removed.  Fastening  the 
hands  in  front  of  the  chest  or  thick  garments  in  the  same  location  renders 
it  more  difficult  to  depress  the  handle  of  the  introducer  sufficiently  to  carry 
the  tube  over  the  dorsum  of  the  tongue. 

"The  gag  is  then  inserted  well  back  behind  or  between  the  teeth  in  the 
left  angle  of  the  mouth  and  opened  widely,  care  being  taken  not  to  do  it 


PLATE  XXV 


Intubation.     First  step.     Index  finger  raising  the  tip  of  the  epiglottis. 
The  tube  guided  along  the  finger.     (Original.) 


Intubation.     The  tube  passing  the  opigkittis.     Entering  the  larynx.      (Original.) 


INTUBATION. 


549 


too  suddenly  or  to  use  too  much  force.  In  children  who  have  not  at  least 
one  bicuspid  on  the  left  side,  the  gag  should  not  be  used,  as  it  slips  forward 
on  the  gums,  and,  besides  being  in  the  way,  is  liable  to  injure  the  incisor 
teeth.  There  is  little  difficulty  in  these  cases  in  keeping  the  mouth  suffi- 
ciently open  with  the  finger,  if  carried  far  enough  to  the  patient's  right 
to  be  out  of  range  of  the  front  teeth.     Allowing  the  child  to  compress  the 


Fig.    176. — The  tube,  passing  the  epiglottis,  entering  the  larynx.      (Original.) 


finger  between  the  gums  for  a  few  seconds  until  the  jaws  relax,  before  carn-- 
ing  it  into  the  fauces,  avoids  the  necessity  for  using  force. 

"An  assistant  stands  behind  the  patient  and  holds  the  head  firmly  by 
placing  one  hand  on  either  side,  and  at  the  same  time  slightly  elevates  the 
chin.  The  operator  stands  in  front  of  the  patient,  holding  the  introducer 
lightly  between  the  thumb  and  fingers  of  the  right  hand,  the  thumb  resting 
on  the  upper  surface  of  the  handle,  just  behind  the  knob  that  serves  to 
detach  the  tube,  and  the  index  finger  in  front  of  the  trigger  support  under- 
neath.    Held  in  this  manner  it  is  impossible  to  use  force  enough  to  make 


550 


THE  INFECTIOUS  DISEASES. 


a  false  passage,  while  if  firmly  grasped  in  the  hand  the  beginner  may,  uncon- 
sciously, exert  sufficient  force  to  lacerate  the  tissues. 

"The  index  finger  of  the  left  hand  is  carried  well  down  in  the  pharynx 
or  beginning  of  cBSophagus  and  then  brought  forward  in  the  median  line, 
raising  and  fixing  the  epiglottis,  while  the  tube  is  guided  along  beside  it  into 
the  lar3Tix.  If  any  difficulty  is  experienced  in  locating  the  epiglottis,  it  is 
better  to  search  for  the  cavity  of  the  larynx,  a  cul-de-sac  into  which  the  tip 
of  the  finger  readily  enters,  and  which  cannot  be  mistaken  for  anything  else. 
Once  in  this  cavity,  the  epiglottis  must  be  in  front  of  the  finger  and  the  latter 


VOCAL  CORDS 


Fig.    177. — Tube,  resting  on  vocal  cords,  in  the  larj-nx.     (Original.) 

is  then  raised  and  pressed  toward  the  patient's  right  to  leave  room  for  the 
tube  to  pass  beside  it.  The  distal  extremity  of  the  tube  should  be  kept  in 
contact  with  the  finger,  and  even  directing  it  a  little  obliquely  toward  the 
right  side  of  the  larj^nx  if  necessary  to  get  inside  the  left  aryepiglottic  fold, 
especially  in  very  young  children.  The  handle  of  the  introducer  is  held 
close  to  the  patient's  chest  in  the  beginning  of  the  operation,  and  rapidly 
raised  as  soon  as  the  end  of  the  tube  has  passed  behind  the  epiglottis;  other- 
wise it  will  slip  over  the  larynx  into  the, oesophagus. 

"Some  operators  hold  the  introducing  instrument  in  the  horizontal 
position  until  the  tube  is  well  back  in  the  fauces,  and  then  swing  it  around 
to  the  middle  line  and  complete  the  operation  in  the  usual  manner.  The 
beginner  is  liable  to  forget  the  latter  movement,  which  is  the  only  objection 
to  this  plan. 


PLATE  XXVI 


Extubation.     First  step.     Gag  in  position.     Extractor  is  guided  along  the  left 
index  finger  until  the  beak  enters  the  lumen  of  the  tube.      (Original.) 


Extubation.     Second  st«p.    The  beak  of  the  extractor  holding  the  tube  firmly; 
the  operator  withdraws  the  tube.      (Original.) 


INTUBATION. 


551 


"As  soon  as  the  cannula  is  inserted  the  introducer  with  obturator  at- 
tached is  withdrawn  by  pressing  forward  the  button  on  the  upper  surface 
of  the  handle  with  the  thumb,  while  counter-pressure  is  made  with  the 
index  finger  on  the  trigger  beneath.  In  removing  the  obturator — the  joint 
in  the  shank  of  which  is  intended  to  facilitate  this  part  of  the  operation — 
the  movements  required  for  insertion  are  reversed.     To  prevent  the  tube 


Fig.  178.— Extubation.  The  left  index  finger  finding  the  tube.  The 
beak  of  the  extractor  guided  into  the  opening  of  the  tube  before  removal 
of  the  tube.     (Original.) 

from  being  also  withdrawn,  the  finger  must  be  kept  in  contact  with  its 
shoulder  either  on  the  side  or  posteriorly, 

"The  tube  should  be  carried  well  down  in  the  lar^-nx  before  detaching 
it;  otherwise  the  lower  aperture  will  be  left  open  and  liable  to  strip  off 
pseudo-membrane  as  it  is  subsequently  pushed  home  with  the  finger. 

"The  gag  is  removed  as  soon  as  the  tube  is  in  place,  but  the  string  is 
allowed  to  remain  in  place  long  enough  to  be  certain  that  the  dyspnoea  is 
relieved  and  that  no  loose  membrane  exists  in  the  lower  portion  of  the 


552 


THE  INFECTIOUS  DISEASES. 


trachea.  In  some  cases  the  presence  of  the  thread  is  desirable  because  it 
excites  more  coughing,  which  is  necessary  to  expel  accumulated  secretious 
and  to  inflate  any  collapse  of  the  lungs  that  may  have  taken  place.  In 
removing  the  string  the  finger  must  be  reinserted  to  hold  the  tube  down, 
but  the  gag  is  rarely  necessary,  as  children  old  enough  to  understand  readily 
open  the  mouth  for  this  purpose.'^ 

The  characteristic  tubal  cough  due  to  a  rush  of  air  through  the  tube 
when  in  the  lar3mx,  if  once  heard,  will  always  be  remembered.    Usually  the 


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Fig.  179. — Baby  K.,  nursing  infant,  eleven  months  old,  suffered  with 
Laryngeal  Diphtheria  complicated  by  Broncho-pneumonia.  Stenosis  re- 
quiring intubation.  Case  seen  in  consultation  with  Dr.  Kahrs  in  Bronx. 
Tube  remained  in  larynx  nine  days.  Child  recovered.  Private  practice 
case.     (Original.) 


presence  of  the  tube  excites  a  paroxysm  of  coughing  and  large  quantities  of 
mucus  and  membrane  will  frequently  be  expelled.  The  effect  most  no- 
ticeable is  the  immediate  relief  of  the  laryngeal  stenosis.  It  is  wise  to  wait 
five  or  ten  minutes  before  withdrawing  the  silk  thread  that  has  been  placed 
in  the  tube.  After  cutting  the  thread  the  finger  should  again  be  placed 
over  the  head  of  the  tube,  and  the  tube  firmly  pressed  down  while  the  string 
is  withdrawn. 


INTUBATION.  553 

There  are  several  important  points  which  must  be  emphasized  in  this 
operation.  In  the  first  place  no  force  is  necessary.  "Occasionally  a  mo- 
mentary spasm  retards  the  immediate  entry  of  the  tube  into  the  larynx,  in 
which  case,  rather  than  use  force,  it  is  best  to  wait  a  second  or  two  for  this 
to  relax,  when  the  tube  will  fall  into  place.  The  introducer  should  be  held 
lightly  between  the  end  of  the  thumb  and  finger,  and  not  grasped  firmly  in 
the  hand.  The  introducer  should  be  kept  exactly  in  the  middle  line ;  other- 
wise the  obturator  will  pinch  in  the  caliber  of  the  tube  and  drag  the  latter 
with  it  as  it  is  withdrawn.  It  often  happens  that  the  child  manages  by  one 
effort  to  slip  down  in  the  nurse's  lap,  while  the  grasp  that  the  assistant 
exerts  tilts  the  head  back,  and  the  tube  may  impinge  on  the  posterior  wall  of 
the  larynx.  The  lines  and  angles  must  be  maintained  to  insure  quick 
intubation.  The  lack  of  observance  and  carelessness  in  these  points 
explain  many  failures  of  inexperienced  operators.  If  the  tube  is  not 
properly  placed  at  the  first  attempt,  it  is  better  to  begin  all  over,  making 
repeated,  short  attempts,  if  necessary,  rather  than  a  single,  prolonged  one." 

Accidents  During  Intubation. — An  inexperienced  operator  will  fre- 
quently be  rewarded  by  fatal  asphyxia.  Prolonged  attempts  to  introduce 
the  tube  will  result  in  apncea. 

"Ten  seconds  is  the  longest  time  that  should  be  occupied  in  each 
attempt,  if  the  child  is  suffering  from  urgent  dyspnoea  at  the  time."  A 
child  cannot  breathe  while  the  finger  is  in  the  throat.  Eepeated  attempts 
will  so  exhaust  the  vitality  of  a  child  that  this  must  be  reckoned  with. 

"The  expert  seldom  requires  more  than  five  seconds  to  complete  the 
operation,  except  in  difficult  cases,  such  as  a  very  small  mouth  and  throat, 
marked  increase  in  the  size  of  the  tonsils,  especially  if  chronic;  extreme 
tumefaction  of  the  epiglottis  and  aryepiglottic  fold,  which  changes  or  ob- 
literates the  usual  landmarks,  and  the  struggles  and  resistance  sometimes 
offered  by  older  children  when  intractable.  In  the  latter,  although  I  have 
never  had  to  resort  to  it,  the  administration  of  an  ancesthetic  would  be  less 
injurious  than  the  exhaustion  and  cyanosis  induced  by  a  prolonged  struggle 
without  it. 

"If  the  tube  has  once  passed  on  the  outside  of  the  larynx,  and  this  is 
recognized  before  it  is  detached  from  the  obturator,  it  is  useless  to  try  to 
rectify  the  position  without  first  depressing  the  handle  of  the  introducer  as 
in  the  beginning  of  the  operation,  because,  owing  to  the  length  of  the  tube, 
the  palate  arrests  the  upward  movement  before  the  distal  extremity  reaches 
the  level  of  the  glottic  opening. 

"In  croup  the  ventricles  of  the  larynx  are  usually  obliterated  by  swelling 
of  the  tissues  and  covered  over  by  the  pseudo-membrane,  and  therefore 
seldom  offer  any  obstacle  to  the  passage  of  the  tube  on  the  first  introduc- 
tion; but  when  the  stenosis  persists  longer  than  usual  and  reintroduction 
becomes  necessary,  it  is  well  to  remember  that  this  may  be  a  source  of  ob- 


554  THE  INFECTIOUS  DISEASES. 

struction.  The  tube  once  having  entered  a  ventricle,  a  moderate  amount 
of  force  is  all  that  is  necessary  to  make  a  false  passage.  I  have  known  this 
accident  to  occur  when  the  operator  was  unconscious  of  having  used  any 
force  whatever.  If  the  patient's  head  be  thrown  too  far  back,  the  tube  may 
also  be  arrested  by  coming  into  contact  with  the  anterior  wall  of  the  larynx 
or  trachea." 

An  accident,  which  fortunately  is  very  rare,  is  the  pushing  of  mem- 
brane downward.  In  this  condition  stenosis  will  not  be  relieved.  In  such 
cases  it  is  advisable  to  extubate  at  once,  and  to  reintubate  by  using  one  of 
the  specially  constructed  tubes. 

Specially  Constructed  Tubes  (see  Fig.  173). — Caliper  tubes,  made  of 
metal,  also  known  as  foreign-hody  tubes,  have  a  much  wider  lumen  than 
the  ordinary  tubes  used  for  intubation.  They  are  also  shorter.  Through 
these  tubes  large  membranes  are  frequently  expelled.  There  are  instances, 
however,  where  large  pseudo-membranes  extend  into  the  trachea  to  the 
smallest  ramifications  of  the  bronchi.  Violent  coughing  paroxysms  fre- 
quently dislodge  these  membranes,  so  that  distinct  casts  of  the  trachea 
and  its  bifurcation  can  be  plainly  made  out.  Several  of  these  easts  were 
seen  by  me  during  my  service  at  the  Willard  Parker  Hospital. 

Intubation  in  Chronic  Stenosis  of  the  Larynx. — O'Dwyer's  rules  and 
indications  for  the  performance  of  intubation  in  chronic  laryngeal  stenosis 
are  as  follows:  (1)  Cicatricial  stenosis,  due  to  injury  to  the  soft  parts  from 
syphilis,  irritants,  and  traumatism.  (2)  Narrowing  of  the  space  both  below 
and  above  the  vocal  bands  from  the  products  of  chronic  inflammation — 
simple,  tuberculous,  specific,  malignant,  or  otherwise,  and  including  such 
conditions  as  the  so-called  pachydermia  laryngis,  and  corditis  vocalis  inferior 
hypertrophica.  (3)  It  is  especially  valuable  in  cases  in  which  tracheotomy 
has  been  performed,  and,  when  the  tracheal  cannula  having  been  worn  for  a 
considerable  length  of  time,  the  upper  part  of  the  trachea  is  filled  with 
granulations  and  the  laryngeal  muscles  have  become  weakened  from  disease. 
In  this  condition  intubation  has  effected  many  brilliant  cures.  (4)  In 
papilloma  of  the  larynx  it  has  been  found  helpful  in  a  fair  proportion  of 
cases,  although  its  results  in  this  disease  are  less  satisfactory  than  in  most 
others  in  which  it  has  been  employed.  (5)  Deformities  of  the  larynx  from 
injury  or  disease  of  its  cartilaginous  framework,  which  have  resulted  in 
constriction  of  the  caliber  of  the  organ,  have  been  cured  by  it.  (6)  It  has 
also  been  used,  with  excellent  results,  in  anchylosis  of  the  crico-arytenoid 
articulations,  and  in  arthritis  deformans  of  the  same  part.  (7)  It  is  useful 
in  various  affections  of  the  nerves  of  the  larynx;  for  instance,  in  hysterical 
contraction  of  the  abductors,  "aphonia  spastica." 

The  Tolerance  of  the  larynx  for  the  Intubation  Tube. — I  have  fre- 
quently seen  children  walking  around  the  wards  of  the  Willard  Parker 
Hospital  who  have  worn  intubation  tubes  about  two  years.    When  one  con- 


INTUBATION. 


555 


siders  the  anatomical  structure  of  the  larynx,  it  is  surprising  that  no 
inflammatory  condition  results  from  the  presence  of  this  foreign  body.  In 
the  article  on  "Broncho-pneumonia"  I  report  a  ease  of  diphtheria  com- 
plicated by  croup  and  later  by  broncho-pneumonia.  Intubation  was  re- 
quired for  the  relief  of  laryngeal  stenosis.  Owing  to  severe  paroxysmal 
cough,  autoextubation  resulted,  requiring,  in  all,  twenty  intubations.  The 
case  finally  recovered. 


Fig.    ISO. — Gavage.     Method  used  in  Forced  Feeding  at  the  Willard  Parker 
Hospital.      (Original.) 

Ulcerations  due  to  the  intithation  tube  have  been  seen  by  me: — 

(1)  In  the  cricoid  division  of  the  larynx,  just  below  the  vocal  cords. 

(2)  At  the  base  of  the  epiglottis,  from  pressure  during  the  act  of 
swallowing. 

(3)  On  the  anterior  wall  of  the  trachea  near  the  distal  end  of  the  tube. 
Ulcerations  resulting  from  an  intubation  tube  have  been  seen  by  me 

post-mortem  in  children  that  were  fed  by  gavage.  I  have  also  seen  ulcera- 
tion where  children  were  fed  by  the  natural  methods.  I  believe  that  feed- 
ing with  the  swallowing  movemejits  incidental  to  the  same  produces  ulcera- 
tion at  the  lower  end  of  the  tube,  because  of  the  up  and  down  riding  of  the 
tube. 


556 


THE  INFECTIOUS  DISEASES. 


A  post-mortem  specimen  of  larynx  and  trachea  was  recently  examined  by  me 
at  the  Willard  Parker  Hospital.  The  child  was  in  the  hospital  twenty-one  days; 
it  was  therefore  an  acute  laryngeal  stenosis.  Three  ulcerations  existed  at  the 
cricoid  cartilage  and  nine  other  ulcerations  existed  at  the  distal  end  of  the  tube. 

Feeding  After  Intubation. — Various  methods  of  feeding  are  in  vogue, 

and  each  clinical  observer  seems  to  be  satisfied  with  his  particular  method. 
Whenever  possible  we  should  try  to  resort  to  the  usual  mouth  feeding.  I 
invariably  feed  semi-5Dlid  food,   such  as  bread  soaked  in  milk,  custard. 


Fig.    181. — Casselberry  Method  of  Feeding.     (Original.) 


junket,  cornstarch  or  rice  pudding,  soft-boiled  eggs,  if  the  child's  age  war- 
rants it ;  also  concentrated  soups  and  broths,  calfsfoot  or  chicken-jelly,  water 
ices  and  ice  cream.  These  articles  of  food  I  have  found  best  adapted  in  a 
very  extensive  experience  in  hospital  and  consultation  practice. 

In  very  young  infants,  breast  or  bottle  fed,  great  care  should  be  exer- 
cised with  the  feeding.  If  a  breast-fed  child  refuses  to  nurse,  the  breast- 
milk  can  be  pumped  off  and  the  infant  fed  every  three  or  four  hours  by 
spoon. 

My  advice  in  intubated  cases:  Use  natural  methods  of  feeding — do 
not  use  gavage — choose  simple  ways.  Eectal  feeding  may  be  tried  if 
vomiting  occurs. 


INTUBATION. 


657 


The  Casselherry  method  of  feeding  consists  in  laying  the  child  flat  on 
its  back  across  the  nurse's  lap,  with  the  head  below  the  level  of  the  body.  By 
this  means  we  avoid  introducing  liquids  into  the  larynx. 

Mamie  B.,  2  years  old,  was  seen  by 
me  through  the  courtesy  of  the  attending 
physician,  Dr.  H.  Weinstein,  on  the  second 
day  of  her  illness.  There  were  patches  of 
diphtheria  visible  on  the  pharynx  and  ton- 
sils. The  temperature  was  101Vb°  F., 
pulse  140.  There  was  also  laryngeal  in- 
volvement noticeable  by  the  croupy  cough. 
An  injection  of  2000  units  of  antitoxin 
was  first  given.  The  colon  was  flushed 
and  the  bowels  thoroughly  emptied.  A 
dose  of  calomel  was  given  and  milk  and 
albumin  water  ordered  for  the  diet. 

Nasal  irrigations  of  saline  solution 
were  ordered  every  two  hours.  An  ice-bag 
was  applied  to  the  neck.  On  the  third 
day  the  temperature  rose  to  102°  F.,  pulse 
130,  respiration  36.  Breathing  labored — 
considerable  retraction  of  the  chest — cough 
very  croupy.  Large  quantities  of  mucus 
were  expectorated.  The  pulse  was  146, 
respiration  40.  Stimulation  was  de- 
manded and  1  drachm  of  whisky  was 
given  every  hour.  Laryngeal  stenosis  was 
so  severe  that  a  hurry  call  was  sent  to  me 
to  intubate.  The  child  was  quickly  in- 
tubated. A  No.  3  rubber  tube  having  a 
coating  of  gelatine  and  alum  was  inserted. 
The  stenosis  was  immediately  relieved. 
The  child  appeared  comfortable  and  fell 
asleep.  Six  hours  after  the  intubation 
the  temperature  was  103°  F.,  pulse  140, 
respiration  40.  Cold  sponging  was  ordered 
and,  owing  to  severe  coughing  when  liquids 
were  given,  semi-solids  were  ordered  while 
the  intubation  tube  was  in  situ.  On  the 
following  day  the  temperature  dropped 
to  101.6°  F.,  and  on  the  third  day  after 
intubation  the  child  was  practically  nor- 
mal. The  tube  was  left  in  the  larynx 
five  days,  and  as  soon  as  the  temperature 
dropped  to  99°  F.  the  child  was  extubated. 
The  patient  made  an  uneventful  recovery. 

No  complications  followed.  I  might  add  that  the  usual  rule  of  administering  15 
grains  of  bromide  of  sodium  or  V12  grain  of  sulphate  of  morphine,  as  an  anti- 
spasmodic, one  hour  before  extubation  was  not  given  in  this  case. 


Fig.  182. — Temperature  Chart  from 
a  Case  of  Diphtheria:  Croup,  In- 
tubation.      (Original.) 


558 


THE  INFECTIOUS  DISEASES. 


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560  TfiE  INFUCtlOtJS  DISEASES. 


A  Study  of  the  Condition  of  the  Upper  Air  Passages  Before  and 

After  Intubation  of  the  Larynx.    Also,  an  Inquiry  Into 

the  Method  of  Feeding  Employed  in  the  Cases.^ 

Laryngeal  stenosis  will  frequently  be  relieved  after  one  intubation  and 
one  extubation.  There  are  other  cases  which  require  several  intubations 
before  a  permanent  cure  results. 

I  have  examined  a  series  of  children  that  were  operated  upon  several 
years  ago.  Two  classes  of  cases  have  been  selected.  One  series  was  seen  at 
the  Willard  Parker  Hospital,  and  the  cases  were  intubated  by  the  resident  or 
assistant  resident  physician.  The  cases  in  this  series  cover  the  years  1896 
to  1900,  and  were  under  treatment  of  Dr.  B.  Gr.  Bryant  and  Dr.  Somerset. 

First  Series.  Children  Intubated  in  the  Hospital. — The  children  ad- 
mitted to  the  Willard  Parker  Hospital  belong,  as  a  rule,  to  the  laboring 
class  of  people.  Exceptionally,  the  service  at  the,  hospital  receives  patients 
of  a  better  class.  All  of  the  children  examined  by  me  belonged  to  the  tene- 
ment house  district  of  New  York  City.  The  houses  are  densely  crowded 
tenements  having  a  minimum  quantity  of  fresh  air  and  sunlight.  It  is 
not  unusual  to  see  cases  from  such  unsanitary  surroundings  ending  fatally. 
These  children  are,  as  a  rule,  very  anaemic  and  are  extremely  susceptible  to 
infection. 

Hospital  Cases  :     10. 
8  cases  required  one      intubation 
1  case    required  three  intubations 
1  case    required  four    intubations 

Day  of  the  Disease. 

4  cases  were  intubated  on  the  2d    day  of  illness 

1  case    was    intubated  on  the  3d    day  of  illness 

2  cases  were  intubated  on  the  4th  day  of  illness 
1  case  was  intubated  on  the  5th  day  of  illness 
1  case  was  intubated  on  the  9th  day  of  illness 
1  case    was    intubated  on  the  14th  day  of  illness 

One  case  intubated  seven  years  ago  has  had  no  illness  since.  Four 
cases  intubated  six  years  ago  are  in  excellent  health  to-day.  One  case  has 
remained  entirely  well.  One  case  had  enlarged  cervical  lymph  nodes.  One 
case  had  pneumonia  one  year  later.  One  case  had  pneumonia  and  paralysis 
and  five  years  later  had  a  second  attack  of  diphtheria,  but  no  laryngeal 
stenosis. 

Five  cases  intubated  three  years  ago  are  in  good  condition  to-day. 
Three  had  measles  and  bronchitis  after  recovery.     One  has  not  had  a 


^  Paper  read  before  the  International  Medical  Congress  held  at  Madrid,  Spain, 
April  26,  1903. 


INTUBATION.  561 

day's  illness  since  intubation.     One  case  had  a  mild  attack  of  croup  two 
years  after  intubation,  but  did  not  require  reintubation. 

Rachitis  seems  to  play  an  important  part  in  the  causation  of  laryngeal 
stenosis,  just  as  we  know  that  rickets  is  met  with  in  laryngismus  stridulus. 
Eight  cases  out  of  the  10  reported  in  this  series  showed  some  form  of 
rickets. 

There  seems  to  be  a  certain  predisposition  for  the  development  of 
laryngeal  stenosis  in  children  affected  with  diphtheria  who  are  rachitic. 

Condition  of  the  Throat. — In  all  of  the  cases  of  this  series  some  form 
of  chronic  tonsillar  or  pharj^ngeal  condition  was  found.  Adenoids  were  also 
seen  in  2  of  these  cases.  Whether  or  no  the  hypertrophied  tonsils  seen  in 
these  cases  were  present  at  the  time  of  intubation  is  not  known.  The  fact 
that  8  cases  out  of  10  still  showed  enlarged  tonsils,  and  1  case,  which  makes 
9  cases,  reported  having  had  a  tonsillotomy  performed,  proves  that  hyper- 
trophied tonsils  must  have  menaced  the  children's  health  before  the 
diphtheria. 

Feedi/ng  During  Infancy. — It  is  certainly  an  interesting  fact  that  all 
of  the  children  in  this  series  were  breast-fed.  When  abnormal  conditions, 
as  rickets,  scurvy,  tuberculosis,  syphilis,  or  other  undermining  disorders, 
exist,  then  recurring  stenosis  of  the  larynx  might  possibly  be  provoked  by 
such  chronic  disease. 

These  cases  of  recurring  stenosis  sometimes  require  months  and,  in 
rare  instances,  years  of  intubating  until  recovery  takes  place.  I  have  fre- 
quently seen  chronic  tube  cases  while  making  my  rounds  in  the  wards  at  the 
Willard  Parker  Hospital. 

Intubation  has,  in  America,  entirely  replaced  tracheotomy  for  the 
relief  of  acute  laryngeal  stenosis.  Eubber  tubes  are  used  exclusively  for 
intubation.  The  old  metallic  tubes  have  long  ago  been  discarded.  Trache- 
otomy is  used  as  a  secondary  operation,  usually  to  cure  "retained  tubes." 
When  laryngeal  stenosis  persists  and  the  patient  cannot  get  along  without 
the  tube,  then  a  tracheotomy  is  frequently  resorted  to. 

Jennings,  of  Detroit,  with  an  equally  large  experience,  says  that 
he  has  never  met  with  the  severer  forms  of  the  difficultj^,  but  that  in  two  or 
three  instances  he  has  had  to  continue  the  intubation  as  late  as  the  third 
week  after  the  first  insertion,  before  recovery  was  complete.  His  associate, 
Shurley,  has  never  had  any  trouble  with  delay  in  the  removal  of  the  tube. 
G-alatti,  in  the  article  above  referred  to,  states  that  he  had  2  chronic 
stenoses  in  31  intubations.  He  reports  Eanke  as  having  had  1  case  in  many 
hundred;  Heubner,  1  in  250,  and  Bokay,  2  in  800.  McNaughton,  of  Brook- 
lyn, says  that  he  has  had  but  few  cases  in  many  hundred,  and  these  recovered 
at  the  latest  within  several  weeks. 


36 


563  THE  INFECTIOUS  DISEASES. 

At  the  Nursery  and  Child's  Hospital  of  New  York  City  there  have  been 
no  noticeably  prolonged  intubations.  The  New  York  Foundling  Hospital 
has  had  6  cases  in  a  total  of  approximately  500.  Investigation  of  the  statis- 
tics at  this  institution  forcibly  illustrates  the  advantages  in  the  use  of 
the  diphtheria  antitoxin.  The  house  physician  complained  to  Dr.  Eogers 
that  before  the  introduction  of  this  remedy  his  predecessors  had  always 
averaged  at  least  one  intubation  a  week,  and  thereby  obtained  much  valuable 
experience;  but  about  the  time  he  came  into  the  hospital,  the  rule  was 
instituted  that  antitoxin  should  be  given  to  every  patient  as  soon  as  there 
was  any  suspicion  of  diphtheria.  The  result  was  that  he  had  never  in  a 
year's  service  had  a  single  opportunity  to  practice  intubation  on  a  living 
subject. 

The  Dorsal  Method  of  Intubation. — Elsewhere  in  this  article  I  have 
referred  to  the  dorsal  method  of  intubation.  The  great  advantage  in  this 
method  lies  in  the  fact  that  an  intubation  tube  can  be  inserted  in  a  child 
suffering  with  laryngeal  stenosis  with  the  aid  of  the  mother  or  nurse 
alone.  With  the  child  lying  on  its  back,  the  arms  and  feet  pinned  in  a 
blanket  or  sheet  to  prevent  struggling,  any  intelligent  person  can  steady 
the  head  and  hold  the  gag  in  position  at  the  same  time,  while  the  physician 
has  both  hands  free  for  the  introduction  of  the  tube. 

The  older  method  required  an  assistant  to  hold  the  child  in  an  up- 
right position,  and  a  second  assistant  to  stand  behind  the  child's  head  to 
steady  the  same  and  to  hold  the  gag  in  position.  The  experience  gained  in 
the  hospital  with  both  methods  has  led  us  to  abandon  the  older  method 
entirely. 

Second  Series.  Children  Intubated  in  Private  Practice. — The  children 
of  this  series  were  seen  in  consultation  with  the  family  physician,  excepting 
1  case  (Case  11),. which  was  referred  to  me  for  personal  treatment.  They 
belong  to  the  better  class  of  children,  which  implies  better  sanitary  sur- 
roundings, better  food  and  prompt  medical  aid  when  the  first  symptoms  of 
illness  are  noticed.  It  was  much  easier  to  study  this  series  of  cases,  as 
the  physician  in  attendance,  as  a  rule,  gave  me  the  required  data. 

Case  X  should  be  excluded  in  this  study,  as  the  child  coughed  up  its 
tube  (auto-extubation)  and  died  of  asphyxia  before  the  physician  arrived. 
Case  IX  must  also  be  excluded,  as  it  was  impossible  to  obtain  satisfactory 
details  concerning  the  progress  of  the  case  after  it  recovered  from  the 
diphtheria. 

6  cases  were  intubated  8  years  ago 

1  case  was  intubated  7  years  ago 
4  cases  were  intubated  5  years  ago 

2  cases  were  intubated  4  years  ago 
2  cases  were  intubated  3  years  ago 
9  cases  were  intubated  2  years  ago 


INTUBATION.  563 

One  of  the  cases  in  this  series  contracted  scarlet  fever  and  died  two 
years  after  intubation.  .  So  that  3  cases  out  of  this  series  must  be  excluded 
leaving  23  cases  from  which  reports  have  been  received. 

Day  of  the  Disease. 

•- '  1  case    was    intubated  on  the  1st   day  of  illness 

■^  11  cases  were  intubated  on  the  2d     day  of  illness 

9  cases  were  intubated  on  the  3d     day  of  illness 

2  cases  were  intubated  on  the  5th  day  of  illness 

Number  or  Intubations  Required. 
15  eases  required  one     intubation 

2  cases  required  two     intubations 

3  cases  required  three  intubations 

1  ease     required  four    intubations 

2  cases  required  five     intubations 

Length  of  Time  the  Tube  was  Worn. 
1  case    26  days  2  cases  7       days 

1  case     25  days  5  cases  6        days 

1  case    22  days  8  cases  5       days 

2  cases  14  days  1  ease     4 'A-  days 
2  cases  12  days 

The  average  length  of  time  the  tube  was  worn  in  the  above  33  cases  was 
91/^  days  or  338  hours. 

Rachitis. — In  this  second  series  of  cases  we  are  dealing  with  children 
brought  up  in  excellent  surroundings.  In  the  families  of  the  better  class 
in  New  York  City  the  majority  of  mothers  do  not  nurse  their  own  infants. 
Wet-nurses  are  not  commonly  employed.  Thus  the  larger  number  of  these 
children  are  to-day  brought  up  by  bottle  feeding.  It  is,  therefore,  no  wonder 
that  in  the  present  series  of  cases  rickets  due  to  malnutrition  or  inanition 
was  very  frequently  encountered.  The  susceptibility  of  the  rickety  child  has 
frequently  been  mentioned  by  many  authors.  In  this  second  series  of  cases 
rachitis  was  associated  in  19  cases. 

Condition  of  the  Throat. — Not  one  of  these  cases  had  a  normal  throat 
at  the  time  of  the  intubation.  Adenoid  vegetations,  enlarged  tonsils,  and 
chronic  rhinopharyngitis  w^ere  met  with  in  almost  every  case.  When  the 
danger  of  a  diphtheritic  laryngeal  stenosis  in  a  child  is  considered,  then  it 
is  certainly  important  to  urge  the  removal  of  hypertrophied  tonsils  or 
adenoids  if  present,  and  to  restore  normal  conditions  in  the  rhinopharynx 
if  possible.  Greater  attention  should  be  bestowed  on  the  nose,  as  the  most 
fatal  cases  are  those  of  nasal  diphtheria  in  which  general  sepsis  follows. 

After-effects  Resulting  from  Intubation. — While  some  physicians  have 
reported  the  existence  of  a  bronchial  catarrh  during  the  first  and  second 
winter  months  following  intubation,  the  majority  of  these  16  cases  reported 


564 


THE  INFECTIOUS  DISEASES. 


absolutely  normal  conditions.  Two  cases  have  had  pneumonia,  in  one  child 
five  years  after  intubation  and  in  the  other  child  three  years  after  intuba- 
tion. 

One  very  interesting  case  in  this  series  was  a  child  (an  idiot)  4  years  old,  seen 
in  consultation  with  Dr.  C.  Hoffman.  This  was  one  of  the  most  trying  eases  and 
required  five  intubations  extending  over  a  series  of  twenty-five  days.  The  child  made 
a  splendid  recovery.  Such  cases  in  private  practice  must  be  invariably  supervised 
by  a  trained  nurse.  In  this  particular  case  careful  feeding  in  addition  to  competent 
nursing  was  the  means  of  saving  the  child's  life. 


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Fig.    183. — LarjTigeal  Diphtheria.     Child  4  years  old;   mentally  deficient. 
Seen  in  consultation  wth  Dr.  C.  Hoffmann.     (Original.) 


Constant  cougli  or  laryngitis  lasting  many  months  was'  encountered  in 
4  cases  of  my  series.  All  in  all,  there  is  no  case  in  my  series  in  which  a 
distinct  bronchial  or  laryngeal  catarrh  could  be  traced  to  or  associated  with 
the  intubation. 


INTUBATION.  565 

Rogers  says:  "As  regards  the  etiology  of  postdiphtheritic  stenosis  of 
the  larynx  and  retained  intubation  tubes,  the  views  of  the  late  Dr.  O'Dwyer 
are,  of  course,  worthy  of  the  greatest  consideration.  Nevertheless,  I  believe 
they  are  wrong.  He  maintained  that  the  condition  was  the  fault  either  of 
the  operator  or  of  the  instruments,  which  means  careless  or  unskilled  inser- 
tion, or  the  use  of  poorly  constructed,  and,  therefore,  improperly  fitting 
tubes.  Formerly,  while  he  was  experimenting  with  and  perfecting  his  in- 
strument, he  sometimes  encountered  ulcerations  and  granulations;  and  the 
2  cases  he  reports  of  granulations  at  the  Ijase  of  the  epiglottis,  where  it 
impinged  upon  the  head  of  the  tube,  might  properly  be  counted  in  this  class. 
At  all  events  there  is  no  other  record  of  a  similar  occurrence  from  the  u^e  of 
the  liard-riibher  tube  as  at  present  made.  It  must  be  admitted,  nowevei,  that 
erosions  and  ulcerations  are  possible  with  a  metal  tube,  as  its  surface  soon 
becomes  rough  from  a  deposit  of  what  is  apparently  calcareous  matter. 
But  WThether  ulcerations  and  subsequent  cicatrices  may  not  be  thus  produced 
has  very  little  to  do  with  the  matter,  as  they  do  not  seem  to  be  the  usual 
cause  of  the  stenosis  in  the  reported  cases.  .  .  .  And  it  is  important, 
from  a  medico-legal  aspect,  as  well  as  for  the  sake  of  intubation,  to  show  that 
neither  the  operator  nor  tube,  ordinarily,  has  anything  to  do  with  a  possible 
postdiphtheritic  stenosis.  It  is  granted  that  lacerations  and  serious  per- 
manent damage  to  the  larynx  can,  of  course,  be  inflicted  by  extreme  lack  of 
skill  or  care ;  but  to  claim  that  this  must  have  happened  in  all,  or  even  some, 
of  the  cases  of  retained  tube  is  not  borne  out  by  the  facts.  A  certain  amount 
of  traumatism  is  necessarily  inflicted  at  every  intubation,  and  if,  by  any 
chance,  a  chronic  stenosis  follows,  the  traumatism  is  always  blamed  for  it. 
That  this  is  wrong,  at  least  in  the  average  case,  is  proved  to  my  mind  by  the 
pathology  of  the  condition.  It  is  the  same  whether  the  stenosis  follows  intu- 
bation or  a  primary  tracheotomy." 

'  •  Causes  of  Recurring  Stenosis. — Emil  Kohl,  in  his  inaugural  address  at 
Zurich,  in  1884,  described  very  fully  the  pathological  condition  of  the 
larynx  in  cases  of  chronic  postdiphtheritic  stenosis  with  retained  tracheal 
cannula.  This  article  demonstrates  most  conclusively  that  not  the  least 
frequent  cause  of  the  difficulty  is  a  chronic  hypertrophic,  subglottic 
laryngitis,  a  chronic  thickening  of  the  soft  parts  between  the  vocal  cords  and 
the  lower  border  of  the  cricoid  cartilage.  The  hypertrophy  of  the  soft  tissue 
was  so  marked  that  respiration,  except  through  tracheal  fistula,  was  impos- 
sible. These  cases,  of  course,  had  never  been  intubated;  and,  therefore, 
the  chronic  inflammation  within  the  larynx  cannot  be  charged  to  the  irrita- 
tion or  traumatism  consequent  upon  the  insertion  or  wearing  of  an  intuba- 
tion tube. 

Another  and  more  frequent  cause  of  the  stenosis  was  shown  to  be 
granulations  and  cicatrices  in  the  neighborhood  of  the  tracheal  wound  or 
cannula.    And  the  nearer  the  cannula  was  to  the  vocal  cords  the  worse  were 


566  THE  INFECTIOUS  DISEASES. 

these  complications.  The  vicinity  of  the  upper  end  of  the  wound  was  more 
prone  to  granulations  and  cicatrices  than  the  lower,  as  the  upper  end  gener- 
ally involved  or  was  close  to  the  larynx,  where  the  mucous  membrane  is 
more  loosely  attached  than  below.  This  bears  upon  the  cause  of  the  stenosis 
described  in  some  of  the  reported  cases  of  retained  tubes  which  have  finally 
been  tracheotomized.  If  the  tracheotomy  has  existed  long  enough,  it,  and 
not  the  original  intubation,  may  have  given  rise  to  the  cicatricial  tissue. 

Incidentally,  it  may  be  noted  that  the  number  of  devices  described  by 
Kohl  for  remedying  a  postdiphtheritic  stenosis  will  illustrate  the  difficulties 
in  the  way  of  successful  treatment  other  than  by  intubation. 

In  speaking  of  the  operative  treatment  of  stenosis  of  the  larynx  follow- 
ing intubation  and  tracheotonw,  Arthur  B.  Duel  says:  "The  important 
points  to  remember:  (1)  About  1  per  cent,  of  all  patients  intubated  for 
acute  laryngeal  stenosis  will  'retain'  the  tube.  (2)  The  cause  of  the  reten- 
tion is  due,  in  the  majority  of  cases,  to  chronic  inflammation  of  the  intra- 
laryngeal  mucous  membrane  and  hypertrophy  of  the  subglottic  tissues,  and 
is  not,  as  has  been  generally  supposed,  the  result  of  granulation,  ulceration, 
or  cicatricial  bands.  (3)  Autoextubation  in  these  cases  is  the  rule,  and 
adds  greatly  to  the  danger  where  an  experienced  intubator  is  not  at  hand. 
As  a  result  of  this  a  large  number  of  such  cases  are  tracheotomized  for  safety. 
(4.)  Where  high  tracheotomies  are  done,  cicatricial  bands  are  almost  certain 
to  form  in  the  trachea  or  lower  part  of  the  larynx  above  the  tracheotomy 
wounds.'' 

The  points  in  treatment  which  should  be  emphasized  are:  (1)  The 
largest  sized  tube  possible  should  be  inserted,  under  an  anaesthetic.  In  case 
of  contraction,  rapid  dilatation  should  be  done  by  beginning  with  the  small 
sizes  and  working  up  to  the  large  special  tube,  which  is  to  be  left  in  place. 
This  special  tube  should  be  as  large  as  can  be  inserted,  and  the  constriction 
below  the  neck  only  '^/^^  inch  smaller  than  the  retaining  swell.  (2)  This 
tube  should  be  left  in,  undisturbed,  for  six  weeks  at  least.  It  should  then 
be  removed,  and,  if  a  cure  has  not  been  accomplished,  it  should  be  replaced 
for  six  weeks  longer. 

To  illustrate  the  above  the  following  case  may  be  cited : — 

Child  B.,  2  years  old,  was  seen  by  me  in  1895,  in  consultation  with  Dr. 
McConville,  of  Brooklyn.  The  child  had  had  a  severe  pharyngeal,  tonsillar  and 
laryngeal  diphtheria.  The  temperature  was  101°  F.,  pulse  140,  respiration  labored. 
Child  cyanotic.  I  intubated  with  a  No.  2  metal  tube,  which  immedia^tely  relieved 
the  laryngeal  stenosis.  The  general  condition  of  the  child  improved  greatly  and 
three  days  later  I  was  requested  to  extubate.  Several  minutes  after  extubation 
marked  laryngeal  stenosis  recurred  so  that  a  second  intubation  was  necessary.  The 
child's  condition  again  improved,  and  when  normal  conditions  prevailed,  in  about 
four  days  I  was  again  requested  to  extubate.  Thus  the  child  was  intubated  and 
extubated  every  four  days  for  a  month.  As  the  family  were  unable  to  retain  the 
services  of  a  competent  trained  nurse,  and  as  the  child  required  frequent  medical 


INTUBATION.  567 

supervision,  the  case  was  transferred  to  the  Gouverneur  Hospital.  Dr.  Rogers 
treated  this  case  as  he  does  all  of  his  "retained  tube"  cases  by  introducing  the 
largest  sized  tube  that  can  be  worn,  and  allowing  the  tube  to  remain  in  situ  four, 
five  or  six  weeks  before  extubating.  After  one  month  of  this  treatment  I  was 
informed  that  extubation  permanently  relieved  the  condition  and  the  child  was  dis- 
charged from  the  hospital  cured. 

Paralysis  of  the  Vocal  Cords. — Very  many  cases  have  been  reported  by 
competent  observers  on  both  sides  of  the  Atlantic.  In  America,  Waxham, 
Eosenthal,  Engelmann,  myself  and  many  others;  in  Europe,  von  Bokay, 
Trump,  Egidi,  Galatti,  Massei,  and  Escat. 

Intubation  in  Hospital  Practice. — ^There  is  a  decided  difference  be- 
tween intubation  in  a  hospital  and  intubation  in  private  practice.  In  the 
Willard  Parker  Hospital,  New  York,  there  are  always  several  physicians 
ready  to  intubate  at  a  moment's  notice.  I  have  seen  more  than  one  case  of 
mild  stenosis  treated  with  antitoxin;  and  careful  dietary  get  well  without 
intubation.  Haste  is  not  necessary,  and  each  case  must  be  carefully 
treated. 

Intubation  in  Private  Practice  is  an  entirely  different  matter.  Johann 
von  Bokay  in  his  review  regarding  intubation  published  in  the  "Transac- 
tions of  the  Section  on  Diseases  of  Children,"  held  at  Hamburg,  1901, 
honors  me  by  the  following  quotation^ :  "Audi  halte  ich  das  Vorgehen 
von  Louis  Fischer,  des  hervorragenden  intubators  aus  New  York,  fiir 
unrichtig,  der  sagt:  Ich  mache  es  mir  zur  Eegel — wenn  ich  sicher  den 
Nachweis  liefern  kann,  dass  es  sich  um  eine  Diphtheria  handelt  und  ich  das 
Vorhandensein  des  Klebs-Loffler-Bacillus  contatirt  habe,  die  intubation 
sofort  vorzunehmen,  wenn  sich  die  geringste  Stenose  zeigt." 

While  his  statement  is  partly  true,  it  does  require  a  slight  modification. 
When  a  mild  case  of  laryngeal  stenosis  is  encountered  in  private  practice, 
then  judgment  must  be  used  regarding  the  time  for  intubation.  The 
points  to  be  considered  are:  the  distance  at  which  the  patient  lives,  the 
amount  of  diphtheritic  infection  that  we  are  dealing  with,  and  the  circum- 
stances of  the  people  in  which  the  case  occurs.  If  the  child  is  fortunate 
enough  to  be  under  the  observation  of  a  competent  nurse,  who  can  recognize 
the  slightest  increase  in  the  stenosis,  watches  the  condition  of  the  heart,  and 
calls  the  physician  the  moment  the  slightest  danger  arises,  then  the  condi- 
tions are  most  satisfactory  and  we  can  wait  with  intubation ;  otherwise  we  are 
compelled  to  intubate  when  slight  evidences  of  stenosis  appear.  J  do  not  ad- 
vocate i/ntubation  the  moment  stenosis  exists.  In  Case  XXI  of  my  series  of 
private  cases  above  reported,  seen  in  consultation  with  Dr.  Harry  Weinstein, 


^My  rule  is  to  intubate  when  the  slightest  stenosis  exists,  provided  the  clinical 
diagnosis  of  diphtheria  has  been  verified  by  the  bacteriological  diagnosis. 


5f)8  THE  INFECTIOUS  DISEASES. 

the  stenosis  of  the  larynx  was  treated  by  an  injection  of  antitoxin,  the  child 
placed  under  the  care  of  a  competent  trained  nurse  with  detailed  instructions 
regarding  progressive  symptoms.  Twelve  hours  later,  when  the  stenosis  in- 
creased in  severity,  I  was  summoned  hurriedly  to  intubate.  In  this  case  the 
child  wore  the  tube  six  days,  and  required  but  one  intubation  to  complete  the 
cure  of  the  stenosis.  In  America  the  majority  of  intubated  cases  occur  in 
private  practice.  Yon  Bokay  states  that  according  to  Jacobi,  only  5  per 
cent,  of  diphtheritic  laryngeal  stenosis  are  treated  in  the  special  (Willard 
Parker)  hospital.      The  rest,  95  per  cent.,  occur  in  private  practice. 

The  smooth  rubber  tube  with  or  without  metal  lining  is  now  generally 
used  for  the  relief  of  laryngeal  stenosis.  Smooth  rubber  tubes,  with  a  re- 
taining swell,  the  advantage  of  the  same  over  the  metal  tube  in  not  having 
calcareous  deposits  after  being  worn  for  weeks  is  certainly  noteworthy.  The 
corrugated  rubber  tubes  which  were  introduced  by  me  several  years  ago  have 
certainly  served  me  very  well  in  many  cases  of  "retained  tube.^^ 

The  follo^^'mg•  case  occurred  in  the  practice  of  Dr.  A.  W.  Newfield.  The  child 
was  about  4  years  old,  and  had  suffered  for  several  years  with  hypertrophied  tonsils 
and  adenoid  vegetations,  in  addition  to  chronic  pharyngitis.  The  family  physician  ad- 
vised the  parents  to  have  the  throat  operated  owing  to  the  danger  of  infection  with 
diphtheria.  This  prophylactic  measure  was  not  carried  out.  I  saw  the  case  on  the 
second  day  of  illness,  in  consultation  with  Dr.  NeM^field,  and  found  diphtheria  in- 
volving the  pharynx  and  tonsils  which  spread  A'ery  rapidly  to  the  larynx.  The  same 
day  intubation  was  required  to  relieve  a  severe  stenosis.  The  stenosis  was  so 
severe  when  I  saw  the  child,  and  the  pulse  so  weak,  that  it  required  a  rapid  intro- 
duction of  the  tube  to  afford  relief.  An  injection  of  3000  units  of  antitoxin  was 
given.  Three  days  later  a  second  injection  of  3000  units  was  made;  so  that  6000 
units  were  injected  in  all.  There  was  recurring  stenosis  when  the  tube  was  re- 
moved. It  was  necessary  to  intubate  within  ten  minutes.  Extubation  was  per- 
formed once  every  five  days,  and  reintubation  was  necessary  a  few  minutes  to  one- 
half  hour  after  removing  the  tube.  Rubber  tubes  only  wei'e  used  in  this  case.  After 
the  second  intubation  an  alum  gelatine  film  was  used  on  the  tube. 

After  the  third  intubation  it  was  deemed  necessarj'  to  use  a  corrugated  tube 
dipped  in  a  solution  of  hot  gelatine  containing  3  per  cent,  of  ichthyol  and  alum. 
This  tube  was  worn  about  five  days.  After  the  extubation  the  child  breathed,  well 
for  about  one  hour  without  a  tube.  A  mild  form  of  stenosis  was  noticed  and  it 
was  deemed  safe  to  reintubate  with  an  ichthyol  alum  gelatine  film  on  a  No.  4  corru- 
gated rubber  tube.  This  tube  remained  about  six  days  and  was  then  removed. 
Stenosis  did  not  recur  and  the  case  was  discharged  cured.  Later  on  the  adenoids 
and  hypertrophied  tonsils  were  removed  and  the  child  has  been  well  since. 

Conclusion. — All  the  children  in  Isoth  these  series  that  recovered  had 
been  breast-fed.  Tliis  form  of  feeding  must  have  had  an  important  bearing 
on  their  bony  development  as  well  as  their  muscular  structure. 

No  chronic  cough  which  could  be  attributed  to  the  wearing  of  the  tube 
was  encountered.  It  was  presumed  by  me  at  the  outset  of  my  investigation, 
that  I  might  meet  with  a  series  of  cases  of  chronic  larjmgitis,  chronic 
tracheitis  and  chronic  bronchitis,  dating  back  to  the  intubation.     We  know 


INTUBATION.  *  569 

that  pressure  of  the  tube  has  frequently  caused  decubitus;  hence,  it  is  pre- 
sumed that  an  inflammatory  process  might  be  invited  from  the  wearing  of 
the  tube.  Comparing  an  equal  number  of  children  of  the  same  age  and 
development  who  never  suffered  with  diphtheria,  nor  were  intubated,  it  was 
foimd  that  they  suffered  with  pneumonia  and  other  infectious  diseases  in  the 
same  proportion  as  children  in  my  series  of  cases.  This  would  seem  to  be 
a  splendid  argument  in  favor  of  intubation,  as  it  shows  two  important 
points : — 

First. — The  tolerance  of  the  larynx  to  a  tube  for  many  weeks,  one  of 
my  cases  having  worn  a  tube  twenty-six  days,  another  case  twenty-five  days. 

Second. — That  a  properly  fitting  tube  constructed  of  rubber  leaves  no 
evidence  of  chronic  inflammation  directly  traceable  to  the  tube.  In  every 
one  of  my  cases  I  questioned  carefully  if  any  catarrh  originated  from,  or 
could  be  associated  with,  the  wearing  or  removal  of  the  tube,  and  received 
negative  replies. 

Equally  interesting  was  it  to  study  the  contour  of  the  thorax  and  to 
see  if  the  development  of  the  thorax  suffered  by  reason  of  these  children 
wearing  tubes. 

In  spite  of  the  fact  that  the  large  majority  in  the  first  series  as  well  as 
in  the  second  were  decidedly  rachitic,  no  deformity  of  the  chest  due  to  imper- 
fect oxygenization  could  be  attributed  to  the  effects  of  the  intubation  tube. 
An  etiological  factor  and  one  on  Avhich  a  great  deal  of  stress  has  already 
been  laid,  is  that  90  jDer  cent,  in  my  first  series  of  cases  suffered  with  chronic 
throat  disease  in  some  form,  such  as  hypertrophicd  tonsils,  chronic  pharyn- 
gitis, or  adenoids.    In  some  all  of  the  above  conditions  were  apparent. 

It  is  safe  to  presume  that  chronic  throat  disease  invites  infection,  and  I 
believe  that  there  is  a  direct  relationship  between  the  seed  and  the  soil.  If 
children's  throats  are  in  a  normal  condition,  then  the  risk  of  infection  is 
reduced  to  a  minimum.  It  is  our  duty,  therefore,  to  urge  all  mothers  to 
have  diseased  conditions  removed,  and  thus  try  to  prevent  the  infection  of 
diphtheria,  which  is  certainly  a  serious  condition. 

Eecukein^g  Laryngeal  Stenosis  Following  Intubation 
AND  Decubitus. 

Etiology. — This  condition  is  primarily  caused  by  forcibly  pushing  a 
tube  into  an  oedematous  or  infiltrated  mucous  membrane.  O'Dwyer  says 
that  it  is  caused  by  using  a  tube  that  is  too  large  for  the  lumen  of  the 
larynx;  usually  in  the  hands  of  inexperienced  operators.  Metallic  tubes 
that  have  been  worn  for  a  long  time  contain  largo  calcareous  deposits — the 
latter  are  due  to  a  deposit  of  lime  salts  contained  in  the  diphtheritic  mem- 
brane— and  when  removing  such  a  tube  during  extubation,  the  mucous  mem- 
brane is  easily  lacerated,  and  thus  ulceration  is  caused  thereby.  One  of  the 
most   important   papers   given   to   the   profession   was   read   by   the   late 


5?0  TBE  INFECTIOUS  DISEASES. 

Joseph  0'Dw}'er.^  In  his  paper  entitled  "Eetained  Intubation  Tubes'^  be 
says:  "The  cause  of  persistent  stenosis  following  intubation  in  laryngeal 
diphtheria  can  be  summed  up  in  the  single  word  'traumatism/  Paralysis 
of  the  vocal  cord  may  possibly  furnish  an  occasional  exception  to  this  rule." 

Thus  an  injury  to  the  larjTix  can  be  done  by  a  tube  that  does  not  fit; 
it  may  result  from  an  imperfectly  constructed  tubC;,  or  from  a  perfect  tube 
that  is  too  large  for  the  lumen  of  the  larynx^  although  proper  for  the  age, 
or  from  a  tube  that  is  perfect  in  fit  and  make  if  not  cleaned  at  proper  inter- 
vals. O'Dwyer  states  that  the  seat  of  the  lesion  that  keeps  up  the  stenosis 
is  just  below  the  vocal  cords  in  the  sub-glottic  division  of  the  larynx,  or  that 
portion  of  the  organ  bounded  by  the  cricoid  cartilage.  Exceptions  to  this 
rule  result  from  injury  produced  by  the  head  of  the  tube  on  either  side  of 
the  base  of  the  epiglottis,  just  above  the  ventricular  bands.  The  reasons 
given  by  O'Dwyer  for  the  existence  of  the  stenosis  at  this  particular  portion 
can  best  be  explained  b}^  the  following : — 

Pathology. — Anatomically,  normall}^,  there  exists  a  constriction  in  the 
cricoid  region.  When  the  mucous  membrane  infiltrates  or  gets  cedematous 
it  swells  to  such  an  extent  and  only  toward  the  center,  as  the  outside  is  sur- 
rounded by  cricoid  cartilage;  and  while  swelling  toward  the  center,  me- 
chanically impedes  respiration  and  thus  calls  for  mechanical  relief,  i.e.,  intu- 
bation. O'Dwyer  states  that  if  a  tube  is  forced  into  the  larynx  in  a  case  of 
this  kind,  ulceration  and  sloughing  of  the  tissues  is  inevitable,  and  in  some 
instances  necrosis  of  the  cricoid  cartilage  can  result  from  interference  with 
the  circulation.  Our  only  safeguard  in  preventing  too  much  mechanical 
injury  as  in  the  condition  above  cited  is  to  introduce  "a  tube  of  small 
caliber." 

In  the  early  stage  of  this  form  of  cases  the  dyspnoea  returns  slowly; 
sometimes  several  days,  or  in  some  instances  only  a  few  hours,  may  pass 
before  the  former  condition  of  laryngeal  stenosis  is  recognized  and  the  neces- 
sity for  the  introduction  of  a  proper  tube  is  demanded. 

When  the  dyspnoea  returns  slowly,  it  means  that  the  lining  membrane- 
of  the  lar}Tix  cannot  swell  while  the  tube  is  in  position  because  it  is  com- 
pressed between  the  tube  and  the  cartilage.  It  requires  some  time  for  the  re- 
appearance of  the  cedematous  tissue,  which  drops  into  the  chink  of  the 
glottis  and  obstructs  the  respiration,  the  latter  condition  being  mechanically 
prevented  as  long  as  the  tube  was  in  situ.  Exceptional  cases  have  been  re- 
ported where  granulation  tissue  springs  up  from  the  antero-lateral  aspects  of 
the  larynx  just  above  the  ventricular  bands.  O'Dwyer  states  that  the 
origin  of  this  growth  is  a  slight  ulceration  or  erosion  of  the  mucous  mem- 
brane at  the  points  corresponding  to  the  greatest  transverse  diameter  of  the 
shoulder  of  the  tube  from  the  pressure  exerted  during  the  act  of  swallowing. 

Paralysis  of  the  Vocal  Cords,  although  known  to  exist,  is  very  hard  to 

*  American  Pediatric  Society,  at  Washington,  May  6,  1897. 


INTUBATION. 


571 


diagnosticate  without  a  proper  laryngoscopic  examination.  Like  other 
forms  of  paralysis  it  comes  very  late  in  the  course  of  the  disease,  and  if, 
after  wearing  an  intubation  tube  for  a  short  time,  laryngeal  stenosis  recurs, 
it  is  safe  to  assume  that  paralysis  of  the  vocal  cords  is  not  the  cause  of  the 
immediately  recurring  stenosis. 


Fig.  184. — Case  seen  in  consultation  with  Dr.  S.  M.  Landsmann, 
Diphtheria.  Laryngeal  stenosis  requiring  intubation.  Normal  conditions 
and  extubation  on  the  fifth  day.  Two  days  later,  on  the  seventh  day  of 
illness,  a  sudden  high  fever,  due  to  over-feeding,  required  diet  and  calomel. 
Case  recovered.      (Original.) 


False  Passage. — Eepeated  forcible  attempts  at  intubation  will  lacerate 
the  tissues.  It  is  not  infrequent  to  enter  the  ventricles  of  the  lar}'nx,  pro- 
ducing a  false  passage  by  such  forcible  attempts  at  intubation.  If  a  false 
passage  has  been  produced,  then  laryngeal  stenosis  will  not  be  relieved,  and 
it  is  much  wiser,  if  an  expert  intubator  cannot  be  found,  to  immediately 
resort  to  tracheotomy.    The  great  danger  of  collapse  due  to  heart  failure 


572 


THE  INFECTIOUS  DISEASES. 


must  always  be  remembered;  hence  it  is  advisable  that  the  operation,  be  it 
intubation  or  tracheotomy,  should  be  done  quickly,  thus  lessening  shock. 

EXTUBATION, 

Eow  to  Extubate. — First  step  in  the  operation:  place  gag  in  position; 
locate  the  tube  with  the  left  index  finger;  guide  the  extractor  along  the 


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DATES  OF  OBSERVATIONS                   | 

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Fig.  185. — Temperature  Chart  from  a  Case  of  Laryngeal  Diphtheria. 
Excellent  Result  of  Intubation  and  Antitoxin.  Doubtful  Prognosis.  Re- 
covery.    (Original . ) 

finger  until  the  beak  enters  the  lumen  of  the  tube.  Second  step  in  the  oper- 
ation: depress  the  handle  of  the  extractor  to  hold  tube  firmly,  and  with- 
draw the  tube  slowly.     (See  Plate  XXVI.) 

l^hen  to  Extubate. — Five  days  is  a  fair  length  of  time  for  the  tube 
to  be  left  in  the  larynx.  The  following  rules  have  served  me  best  in  a 
very  large  experience  in  hospital  and  private  practice : — ■ 

Let  the  child's  condition  be  the  guide  as  to  when  to  extubate.  My 
advice  is  to  leave  the  tube  in  the  larynx  at  least  four  days,  then  remove  the 
same. 


EXTUBATION.  573 

The  question  to  be  considered  is.  Can  the  child  undergo  the  shock  of 
extubation,  and,  if  need  be,  reintubation  ? 

If  the  temperature  is  over  100°  F.,  and  the  pulse-rate  is  small,  rapid, 
and  over  120,  it  is  better  to  wait  vrith  the  extubation. 

A  rubber  tube  left  in  the  larynx  does  not  have  calcareous  deposits  as 
we  find  them  on  the  metal  tubes;  hence  there  is  no  danger  in  leaving  a 
rubber  tube  in  situ  for  several  weeks. 

If  the  tube  is  plugged  with  mucus  or  membrane  it  may  be  necessary  to 
remove  the  tube  and  clean  it.  A  rattling  or  crowing  sound  in  addition  to 
laryngeal  stenosis  usually  indicates  this  condition. 

At  the  Willard  Parker  Hospital  there  is  no  definite  rule  as  to  the 
number  of  days  a  tube  remains  in  the  larynx.  Individual  conditions 
govern  the  time  of  extubation.  In  some  cases  tubes  are  removed  after 
forty-eight  hours.  The  severity  of  the  cases  admitted  to  the  hospital  and 
the  complication  must  be  taken  into  consideration.  Uncomplicated  cases 
may  be  extubated  any  time  between  the  third  and  seventh  days  when  the 
oedema  of  the  larynx  subsides.  In  a  few  instances  the  child  expels  the  tube 
without  having  recurring  stenosis.  This  auto-extubation  is  occasionally 
seen ;  it  is  Nature's  method  of  removing  a  foreign  body  after  the  subsidence 
of  the  inflammatory  condition. 

Choice  Between  Intubation  and  Tracheotomy. 

In  cases  where  operation  is  indicated  it  may  be  said  that  intubation  has 
steadily  grown  in  favor,  and  its  advantages,  when  it  is  indicated,  are  so 
obvious  as  to  require  no  recapitulation  here.  On  the  other  hand,  conditions 
are  sometimes  present  that  render  intubation  impracticable  or  inadmissible, 
or  at  least  render  tracheotomy  preferable.  It  is  therefore  desirable  to 
keep  clearly  in  mind  the  factors  that  determine  the  choice  in  favor  of 
one  or  the  other  of  these  operations.  This  subject  has  received  con- 
sideration in  a  study,  by  Drs.  George  Alsberg  and  Sigmund  Heimann,  of  the 
cases  of  diphtheria,  to  the  number  of  4033,  observed  at  the  Kaiser  und 
Kaiserin  Friedrich  Kinderkrankenhaus,  in  Berlin,  for  the  ten  years  from 
1891  to  1900.  As  a  result  of  this  analysis  it  is  concluded  that  operative  in- 
tervention in  cases  of  stenosis  of  the  larynx  of  slight  and  moderate  degree 
should  be  obviated  as  far  as  possible  by  means  of  antitoxin  and  the  employ- 
ment of  sprays.  Primary  intubation  is  indicated  in  all  cases  of  stenosis  of 
the  larynx  of  severe  degree  in  which,  so  far  as  the  clinical  picture  makes  it 
appear  possible,  a  cutting  operation  can  be  avoided.  Primary  tracheotomy 
is  indicated  in  the  presence  of  asphyxia  and  collapse,  of  pneumonia,  of  severe 
heart  disease,  of  paralysis  of  the  palate  and  diaphragm,  of  profound  ana- 
tomic changes  in  the  pharynx,  as  well  as  marked  tumefaction  of  the  entire 
pharyngeal  structures  when  necrotic. 


574  THE  INFECTIOUS  DISEASES. 

Secondary  Tracheotomy  is  indicated  when  the  symptoms  of  stenosis 
persist  in  marked  degree  with  the  tube  in  place,  providing  its  lumen  is  not 
occluded,  when  pneumonia  supervenes,  and  when  paralysis  of  the  palate 
and  diaphragm  supervenes.  Intubation  is  not  recommended  in  nursing  in- 
fants by  some  writers  on  account  of  the  diminutiveness  of  the  parts  and  of 
the  narrow  lumen  of  the  pharynx,  but  especially  on  account  of  the  increased 
difficulty  in  feeding  from  the  presence  of  the  tube,  which  at  this  time  of 
life  is  of  vital  importance.  My  personal  experience  is  just  the  reverse,  and 
my  results  have  been  excellent.^ 

Tracheotomy   (In  Acute  or  Subacute  Laryngeal  Stenosis). 

If  laryngeal  stenosis  persists  in  spite  of  intubation,  then  secondary 
tracheotomy  is  indicated.  When  extensive  csdema  of  the  larynx  exists,  in 
which  case  intubation  fails  to  relieve,  tracheotomy  may  be  required.  I  have 
frequently  met  surgeons  who  were  well  posted  on  tracheotomy,  but  were  not 
familiar  with  the  delicate  modus  operandi  of  intubation. 

If  laryngeal  stenosis  threatens  life,  and  the  physician  is  not  acquainted 
with  the  method  of  intubation,  then  by  all  means  perform  tracheotomy, 
rather  than  risk  "experimental  intubation." 

When  emergencies  arise  they  should  be  met  by  quick  action.  An  in- 
teresting case  of  suffocation  due  to  laryngeal  stenosis  was  told  to  me  by 
my  friend.  Dr.  George  P.  Shrady : — 

A  child  suffering  with  croup  suddenly  collapsed  and  was  thought  dead,  when 
Dr.  Shrady,  in  the  emergency,  took  a  razor  which  was  handy  and  made  an  incision 
into  the  trachea.  He  used  a  bent  hairpin  instead  of  a  tracheaL  dilator.  The  child 
breathed  as  soon  as  oxygen  was  admitted.     The  case  recovered. 

Tracheotomies  Performed  {Willard  Parker  Hospital,  1911)  with  Day  of  Disease  and 
Number  of  Days  Tracheotomy  Tube  Remained  in  the  Larynx. 

Total  number  of  tracheotomies  performed  4 

Tracheotomized  on  first  day  of  disease 3 

Tracheotomized  on  second  day  of  disease 1 

Tracheotomy  tube  remained  in  larynx  one  day  1 

Tracheotomy  tube  remained  in  larynx  two  days  2 

Tracheotomy  tube  remained  in  larynx  four  days 1  - 

Result,  3  deaths;  1  recovery. 

Tracheotomies  performed  before  admission    2 

The  Operation. — Ancesthetic:  If  time  permits,  a  few  drops  of  chloro- 
form should  be  given.  If  septic  stupor  exists  then  no  anesthetic  should  be 
given. 

The  high  operation,  "tracheotomie  superieure,"  in  which  the  incision  is 


^  See  case  of  Baby  R.  in  the  practice  of  Dr.  Kahrs,  "Intubation  in  Private 
Practice." 


TRACHEOTOMY.  575 

made  in  the  upper  portion  of  the  trachea,  is  preferred  to  the  lower  operation, 
advised  by  Trousseau,  known  as  ''tracheotomie  inferieure." 

The  upper  portion  of  the  trachea  is  quite  superficial  and  it  is  best  to 
make  an  incision,  exactly  in  the  median  line,  at  least  two  inches  in  length. 
It  is  important  to  remember  that  the  branches  of  the  inferior  thyroid  veins 
are  immediately  under  the  place  chosen  for  the  operation;  hence  the  parts 
must  be  carefully  dissected  with  a  blunt  instrument,  such  as  the  back  of  a 
scalpel,  until  the  trachea  is  reached.  If  there  is  severe  bleeding  the  veins 
should  be  seized  with  a  forceps  unless  emergency  demands  rapidity  of  action. 
The  dissection  should  be  continued  until  the  trachea  is  reached.  When  there 
is  considerable  oozing  of  blood,  and  our  view  is  thus  obstructed,  we  must 
remember  to  keep  in  the  center  of  the  throat,  which  invariably  brings  us  to 
the  rings  of  the  trachea.  By  placing  the  finger  in  the  wound  we  will 
feel  the  respiratory  movement  of  the  trachea.    When  the  trachea  is  reached 


Fig.    186.— Silver   Trachea   Cannula 

used  in  tracheotomy.  Fig.    187. — Hard-rubber  Trachea   Cannula. 

it  should  be  hooked  up  with  a  tenaculum  and  an  incision  made  large 
enough  to  admit  the  tracheotomy  tube.  The  rush  of  air,  so-called  tubal 
sound,  characteristic  of  intubation  is  also  heard  when  tracheotomy  is 
properly  performed. 

After-effects  of  the  Tracheotomy  Tube. — The  presence  of  the  tube  in 
the  trachea  invariably  excites  cough.  This  expels  loose  membranes  and 
other  viscid  accumulations.  High  fever  sometimes  follows  this  operation, 
although  as  a  rule  the  temperature  will  only  reach  101°  or  102°  F. 

The  pulse-rate  should  be  carefully  observed;  a  gradually  increasing 
pulse-rate  during  the  first  three  days  after  the  operation  is  a  very  bad  sign. 

Complications.- — Broncho-pneumonia  and  nephritis  are  to  be  feared,  for 
they  frequently  terminate  fatally.  The  treatment  of  complications  is  the 
same  as  though  the  disease  existed  independent  of  the  operation. 

After-treatment. — Careful  aseptic  methods  must  be  the  rule  from  the 
moment  the  child's  stenosis  is  relieved.  The  infection  of  the  wound  will 
always  be  an  added  source  of  danger.  As  the  majority  of  cases  of  trache- 
otomy will  be  performed  for  extensive  pseudo-membranous  stenosis,  we  must 
remember  that  septic  diphtheria  per  se  may  cause  death  independent  of  the 


576  THE  INFECTIOUS  DISEASES. 

added  danger  incident  to  the  opening  of  the  trachea.  All  oozing  of  blood 
must  be  checked ;  pressure  with  sterile  gauze  saturated  with  Monsell's  solu- 
tion has  served  me  well.  I  have  also  used  gauze  dusted  with  a  powder  con- 
sisting of : — ■ 

IJ  Europhen    7  parts 

Alum   3  parts 

To  Chech  Hcemorrhage. — The  local  application  of  adrenalin  solution, 
1  to  5000,  is  very  valuable  during  the  operation. 

The  internal  cannula  should  be  removed  and  cleansed  every  two  or  three 
hours,  wiped  dry  and  replaced.  In  rare  instances  it  may  be  necessary  to 
cleanse  the  cannula  less  frequently.  This  can  best  be  determined  by 
watching  the  respirations  and  instructing  the  trained  nurse  as  to  when  the 
caliber  of  the  tube  requires  cleansing.  Noisy,  rattling  sounds  due  to  the 
presence  of  mucus  in  the  tube  do  not  necessarily  mean  that  the  cleansing  of 
the  cannula  is  urgent,  if  the  child  is  quiet  or  asleep.  If  the  child  is  restless 
and  turns  its  head  from  side  to  side,  and  usually  mucous  rattling  is  heard  in 
addition,  then  it  is  an  indication  for  cleansing  the  tube. 

Cleansing  the  Wound. — Each  day  following  a  tracheotomy,  it  is  advisa- 
ble to  place  the  child  on  the  operating  table,  withdraw  the  tracheotomy  tube 
and  replace  it  with  a  new  one. 

A  writer  states  that  "after  the  second  or  third  removal  the  larynx 
should  be  examined  to  see  if  it  is  free  and  there  is  no  further  use  for  the 
cannula.''  My  experience  with  tracheotomized  cases  has  not  been  as  good  as 
that,  for  rarely  have  I  seen  a  tracheal  cannula  that  could  be  dispensed  with, 
although  antitoxin  was  administered,  in  less  than  seven  to  twenty-one  days. 
The  severity  of  my  cases  may  account  for  the  difference  in  experience.  At 
times,  in  spite  of  the  greatest  amount  of  care,  even  in  the  hands  of  experi- 
enced operators,  cicatrices  of  the  trachea  resulting  in  permanent  contraction 
or  exuberant  granulations  at  the  site  of  incision  will  require  the  continued 
use  of  the  tracheotomy  tube,  as  in  cases  described  in  the  article  on  "Intuba- 
tion," known  as  "retained-tube  cases." 


CHAPTER  VII. 

RUBELLA  (ROTHELN,  GERMAN  MEASLES,  FALSE  MEASLES). 

EuBELLA  is  an  exanthematous  eruption  simulating  measles.  Oorlett's 
description  of  rubella  is  so  classic  that  I  give  it  word  for  word.^ 

"Eubella  is  a  mild  form  of  infection  which  always  follows  a  benignant 
course  and  first  appears  as  a  general  or  constitutional  disease,  accompanied 
by  a  slight  rise  of  temperature  and  slight  feeling  of  illness.  In  this  it 
conforms  to  the  other  affections  of  this  class. 

"The  local  manifestations,  while  partaking  of  the  character  of  those 
observed  in  both  scarlet  fever  and  measles,  are  distinct,  and  possess  an 
individuality  which,  as  a  rule,  may  be  recognized  by  the  trained  eye. 

"Etiology. — While  we  have  no  exact  knowledge  of  the  cause  of  the 
disease  and  in  what  respect  the  virus  differs  from  that  of  other  diseases  to 
which  it  bears  the  closest  resemblance,  yet  we  do  know  that  it  is  contagious, 
and  always  gives  rise  to  a  like  disease :   in  short,  conforms  to  the  type. 

"It  occurs  but  once  in  the  individual,  from  which  we  infer  that  it  is 
self-protective,  while  it  affords  no  protection  to  or  modification  of  measles 
or  scarlatina;  nor  has  it  appeared  that  they  offer  any  protection  against 
rubella.  It  must  be  remembered,  moreover,  tha,t  even  mild  forms  of  the 
various  exanthemata  are  self -protective.  The  fact  that  the  patient  has  had 
at  some  previous  time  either  scarlet  fever  or  measles,  or  both  of  these 
affections  in  a  well-marked  degree,  often  leads  to  its  recognition.  Some- 
times, even  before  its  true  nature  has  been  definitely  settled  in  the  mind 
of  the  medical  attendant,  the  disease  disappears. 

"Like  the  other  exanthemata,  it  always  appears  in  the  form  of  an 
epidemic,  which  seems  to  bear  little  or  no  relation  to  epidemics  of  other 
diseases,  such  as  scarlet  fever  or  measles." 

Bacteriology  and  Pathology. — Owing  to  the  mild  character  of  the  dis- 
ease, the  pathological  changes  have  not  been  studied.  There  are  certain 
changes  seen  in  the  skin,  described  by  Thomas.  Nothing  definite,  however, 
can  be  stated.  Bacteria  in  the  blood  of  children  suffering  with  rubella  have 
been  described  by  several  authors;  these  are  by  no  means  pathognomonic 
of  this  condition. 

"It  sometimes  occurs  independently;  again,  two  or  more  of  the  epi- 
demic exanthemata  prevail  at  the  same  time.  It  must  be  admitted  that  ex- 
traneous conditions  of  weather  and  possibly  of  sanitation  predispose  in  a 
like  degree  to  all.  Though  epidemics  of  nibella  seem  to  occur  at  less  fre- 
quent intervals  than  do  those  of  either  scarlatina  or  measles,  there  can  be  no 
doubt  that  very  many  epidemics  of  rubella  escape  recognition,  and  are  re- 

^  For  a  very  minute  description  of  this  disease  the  reader  is  referred  to  Corlett's 
"Treatise  on  the  Acute  Exanthemata."    Published  by  F.  A.  Davis  Company. 

87  (57Y) 


578  THE  INFECTIOUS  DISEASES. 

garded  as  mild  or  aberrant  forms  of  one  or  the  other  of  the  first-named 
affections.  While  the  author  believes,  with  Atkinson,  that  unless  more 
exact  methods  are  adopted  in  the  study  of  the  exanthemata  there  is  still 
danger  of  endless  confusion,  and  that  the  practice  of  relegating  all  mild  or 
otherwise  anomalous  forms  of  measles  or  scarlatina  to  rubella  is,  as  it  was 
thirteen  years  ago,  far  too  prevalent;  yet  the  remedy  lies  in  giving  to  this 
important  group  of  affections  a  more  conspicuous  position  than  it  now  holds 
in  the  curriculum  of  clinical  instruction.^' 

The  period,  of  incubation  is  usually  from  fifteen  to  eighteen  days. 

In  New  York  City  cases  of  rubella  are  excluded  from  school  for  one 
week,  at  the  end  of  which  time  they  will  be  readmitted  on  a  medical  certifi- 
cate. Children  in  the  family  who  have  had  the  disease  may  remain  in 
school. 

Symptoms  and  Diagnosis. — ^The  symptoms  may  be  so  mild  that  they 
are  frequently  overlooked.  The  prodromal  symptoms  appear  a  few  hours 
before  the  rash  is  seen.  Some  authors  state  that  in  the  majority  of  cases 
they  are  wholly  absent.  I  have  frequently  seen  catarrhal  symptoms  such 
as  coryza,  in  addition  to  suffusion  of  the  eyes,  on  the  day  previous  to  the 
eruption. 

Throat  symptoms,  such  as  congestion  and  swelling  of  the  tonsils  and 
fauces,  are  usually  seen.  'Cough  and  hoarseness  may  also  be  present.  The 
buccal  mucous  membTane  does  not  have  an  enanthem.  Forchheimer^ 
describes  what  he  considers  a  characteristic  enanthem  in  rubella  which 
appears  simultaneously  with  the  exanthem  and  remains  from  12  to  14 
hours.  Its  favorite  location  is  on  the  soft  palate,  sometimes  extending  to 
the  hard  palate.  It  consists  of  small,  discrete,  dark-red  but  not  dusky 
papules,  which  soon  disappear,  leaving  no  trace  behind.  The  rest  of  the 
mouth  may  or  may  not  be  congested. 

Sometimes  there  is  anorexia  and  occasionally  nausea  or  vomiting.  J. 
Lewis  Smith  describes  convulsions  seen  in  the  disease.  The  temperature 
varies  between  100°  and  101°  F.,  rarely  higher.  The  tongue  is  not  as 
thickly  coated  as  in  measles,  although  the  papillas  may  be  enlarged.  These 
projecting  papillae  appear  on  the  tip  of  the  tongue.  The  characteristic 
strawberry  tongue  is  absent. 

Sneezing  may  be  present  and  coryza  may  be  absent,  or  vice  versa. 

Thierfelder^  states  that  "swelling  of  the  subauricular  and  superior  jugu- 
lar lymphatic  glands  may  be  looked  upon  as  a  constant  prodromal  symptom.'' 
Atkinson^  says  "enlargement  of  the  superficial  lymphatic  glands  of  the  neck 
may  be  the  most  striking  symptom,  and  sometimes  attracts  attention  several 
days  before  the  beginning  of  the  eruption." 


^  "German  Measles,"  Twentieth  Century  Practice  of  Medicine,  New  York,  1898. 
i' Thierfelder :     Greifsw.  Med.  Beitr.,  B.  ii,  Ber.,  p.  14,  1864. 
'Atkinson    (loc.  cit.,  p.  23). 


RUBELLA.  579 

Corlett*  says  "his  cases  show  adenopathy  in  9G  per  cent.,  of  which  the 
maxillary  and  superficial  or  post-cervical  were  the  most  frequently  in- 
volved; next  the  occipital,  posterior  and  anterior  auricular;  and  sometimes 
the  superficial  inguinal,  axillary,  and  the  e])itrochlear.  In  the  neck  the 
inflammation  may  he  sufficiently  severe  to  interfere  with  free  movement,  and 
in  two  or  three  instances  it  has  given  rise  to  marked  ccdema  of  the  sur- 
rounding parts."  Suppuration  of  the  glands  is  never  observed.  The 
lymphatic  ganglia  are  also  involved  in  the  regions  affected.  The  spleen  is 
seldom  involved. 

Pauline  M.,  6  years  old,  was  brought  to  my  office  in  an  apparently  good  con- 
dition. 1  was  told  that  the  child  had  a  rash  on  her  chest  and  back,  and  that  the 
temperature  was  100°  F.  in  the  rectum.  There  was  sneezing,  but  no  cough  nor 
bronchial  symptoms.  There  was  an  enlargement  of  the  glands  on  both  sides  of  the 
neck  along  the  posterior  border  of  the  sterno-mastoid  muscle.  The  buccal  mucous 
membrane,  pharynx,  and  tonsils  were  but  slightly  inflamed.  The  conjunctivae  were 
of  a  deep  pink  color.  The  rash  was  scattered  over  the  abdomen  and  chest  and  was 
erescentic  in  its  arrangement,  similar  to  that  seen  in  measles.  The  highest  tempera- 
ture reached  was  101°  F.,  in  the  evening,  pulse  was  100,  and  the  respiration  24.  The 
treatment  consisted  in  giving  a  mild  laxative  and  liquid  diet.  Strict  isolation  was 
insisted  upon.  The  eruption  remained  about  three  days.  The  child  recovered 
without  any  complication. 

The  Eruption. — The  rash  is  first  seen  on  the  face  and  scalp.  It  is 
described  as  "faint  pinkish  macule,  at  first  discrete,  but  sometimes  becoming 
more  or  less  confluent  within  a  few  hours."  The  eruption  spreads  down- 
ward to  the  neck  and  upper  part  of  the  abdomen  until  the  uj)per  and  lower 
extremities  are  covered.  The  palms  and  soles  are  usually  associated  in  this 
general  eruption.  The  eruption  reaches  its  full  development  after  one  or  two 
days.  It  spreads  slowly  and  fades  on  the  face  wdien  it  is  about  reaching  its 
height  on  the  lower  extremities.  Hardaway  believes  that  this  dissimilarity 
in  the  appearance  of  the  eruption  is  a  valuable  means  of  distinguishing  ru- 
bella from  measles.  "The  individual  lesions  are  sometimes  perceptibly  ele- 
vated and  vary  in  size  from  a  pin-head  to  a  small  bean."  They  are  often 
slightly  elongated  or  irregularly  round  in  shape,  with  an  ill-defined  border, 
and  disappear  completely  on  pressure.  Unlike  measles,  they  show  no 
tendency  to  form  groups,  clusters,  or  crescents,  and  in  some  cases  manifest 
a  feebler  predilection  to  coalesce.  Sometimes,  however,  when  confluent  they 
extend  at  the  periphery,  coalesce,  and  form  extensive  areas,  when  the  re- 
semblance to  scarlatina  may  lead  to  an  error  in  diagnosis. 

"Usually  the  plaques  thus  formed  are  found  only  on  certain  parts,  while 
on  the  remaining  portions  of  the  body  the  eruption  presents  the  more  usual 
appearance.      The  color  is  always  lighter  than  that  observed  in  scarlet 


*  Corlett,  "A  Treatise  on  the  Acute  Infectious  Exanthemata,"  p.  356. 


580 


THE  INFECTIOUS  DISEASES. 


fever,  and  in  a  strong  light  the  slight  elevations  which  correspond  to  the 
original  lesions  may  be  discerned.  Further,  the  eruption  is  fairly  uniform 
in  color  and  may  be  described  as  of  a  faded  rose,  or  pink  tint^,  never,  in  my 
experience,  presenting  the  fiery  red  of  scarlatina  nor  the  dusky,  bluish  red  of 
measles," 

Subjective  Symptoms. — These  are  usually  so  mild  that  children  do  not 
complain.  I  have  seen  cases  of  rubella  in  the  Kaiser  and  Kaiserin  Frederick 
Hospital,  in  Berlin,  while  making  rounds  with  Professor  Baginsky,  which 
were  of  a  very  mild  nature  and  in  which  hardly  any  subjective  symptoms 
were  complained  of. 

The  Fever. — A  peculiarity  of  this  condition  is  that  the  fever  does  not 
correspond  with  the  eruption,  in  intensity.     Von  Nymann  studied  119  cases 


OAT£ 

11 

iZ 

13 

iU- 

iS 

TEMP. 
FAHR. 

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M 

E 

M 

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loi'  :t 

:i 
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i. 

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^ 

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^= 

Fig.    188. — Temperature  Chart.     Case  of  Rubella.      (Original.) 


of  rubella.      He  found  that  58  cases  showed  no  rise  in  temperature.      In 
the  remaining  61  cases  the  temperature  was  as  foUows: — 

In  39  cases  the  highest  record  was  100.4°  F.  (38.0°  C.) 

In  14  cases  the  highest  record  was  101.3°  F.  (38.5°  C.) 

In     6  cases  the  highest  record  was  102.2°  F.  (39.0°  C.)  ' 

In     2  cases  the  highest  record  was  103.1°  F.  (39.5°  C.) 

Fever  never  remains  more  than  four  days  unless  some  comjjUcation  ex- 
ists. The  pulse  and  respiration  do  not  show  much  change,  but  usually  cor- 
respond with  the  temperature.      Sometimes  a  slight  albuminuria  is  present.  , 

Desquamation. — A  general  desquamation  is  absent.  Just  as  the  rash 
spreads  from  place  to  place  and  is  regional  in  character,  so  also  is  the 
desquamation  regional.  There  is  therefore  no  distinct  stage  of  desquama- 
tion that  can  be  applied  to  the  disease  as  a  whole. 

Differential  Diagnosis. — The  following  distinctive  points  are  taken 
from  Corlett: — 

"First. — That  rubella  is  sometimes  feebly  contagious,  while  measles  is 
always  violently  contagious. 


RriJELLA.  581 

"Second. — The  prodromal  stage  is  always  short  and  quite  insignificant 
in  rubella,  while  in  measles  it  continues  from  three  to  four  days. 

"^'Third. — In  measles  the  prodromal  stage  is  usually  accompanied  by 
marked  constitutional  symptoms,  with  catarrh  of  tlie  upper  air  passages, 
lacr}iuation,  photophobia,  and  a  more  or  less  characteristic  eruption  in  the 
mouth,  which  appears  from  twelve  to  forty-eight  hours  before  the  cutaneous 
exanthem.  In  rubella  no  characteristic  prodromata  are  observed,  and  only 
at  the  beginning  of  the  eruptive  stage  is  there  usually  a  slight  hyperemia  of 
the  conjunctiva?,  of  the  faucial  mucous  membrane,  and  rarely  of  the  upper 
air  passages.  On  the  soft  palate  and  uvula  there  is  sometimes  a  punctate  or 
faint  macular  enanthem,  which  by  some  is  considered  distinctive.  Even  in 
mild  cases  of  measles  the  disturbance  of  the  mucous  membranes  is  more 
severe  than  in  severe  cases  of  rubella,  and  there  is  always,  so  far  as  I  have 
observed,  a  bluish  or  skim-milk  tint  to  the  mucous  membrane  of  the  mouth, 
which  I  have  never  found  in  rubella.  In  rubella,  sore  throat  is  present  in 
nearly  all  cases,  while  in  measles  sore  throat  is  uncommon. 

"Fourth. — The  eruption  in  rubella  appears  most  frequently  on  the  first 
and  second  day,  rarely  later.  It  often  disappears  from  parts  first  attacked 
before  other  regions  become  involved.  It  is  of  a  pale  red  or  pinkish  color, 
very  rarely  assuming  a  dusky  tint,  and  the  individual  spots  are  surrounded  by 
a  faint  areola,  thus  obscuring  the  outline  of  the  lesion.  The  spots  are 
papulo-macular,  for  the  most  part  round  or  slightly  oval  in  shape,  and 
present  no  tendency  to  form  crescents  or  groupings.  Sometimes  by 
coalescing  they  unite  to  form  extensive  areas,  which  in  all  cases,  either  at 
the  periphery  or  on  more  remote  parts,  are  associated  with  the  discrete,  small 
macules  which  give  character  to  the  eruption.  The  rash  rarely  lasts  longer 
than  three  days,  and  most  frequently  it  disappears  on  the  upper  part  of  the 
body  on  the  second;  while  in  measles  the  eruption  almost  always  appears 
on  the  morning  of  the  fourth  day,  sometimes  on  the  third,  and  rarely 
earlier.  In  measles  the  color  is  of  a  dark  or  purplish  red,  and  the  lesions 
are  well  defined,  with  normal  skin  intervening.  They  enlarge  at  the 
periphery  and  show  a  marked  tendency  to  form  groups  and  crescents.  These 
are  especially  marked  on  the  face,  neck,  and  upper  part  of  the  trunk.  In 
all  cases  the  individual  lesions  are  larger  than  in  rubella ;  so  that  the  whole 
surface  of  the  body  may  be  involved  at  the  same  time,  consequently,  it 
remains  longer  than  that  of  rubella,  lasting  from  four  to  five  days,  or  longer, 
when  defervescence  begins. 

"Fifth. — In  rubella  the  superficial  lymphatic  glands  of  the  neck  are 
nearly  always  involved,  being  swollen  and  sometimes  painful ;  while  in 
measles  marked  or  painful  enlargement  of  the  glands  of  the  neck  is 
decidedly  uncommon. 

"Sixth. — In  rubella  the  temperature  may  be  only  slightly  above  the 
normal  at  any  time  during  the  course  of  the  disease,  and  it  rarely  exceeds 


582  THE  IXFECTIOrS  DISEASES. 

102°  F.  (38.8°  C).  Nor  is  the  temperature  curve  in  any  way  characteristic 
of  the  affection.  Further,  it  is  usually  of  short  duration  and  rarely  contin- 
ues beyond  the  second  or  third  day.  In  measles  fever  is  always  present  and 
the  temperature  is  sometimes  high.  There  is  an  initial  rise  of  temperature 
during  the  prodromal  stage,  which  usually  subsides,  returning  just  previous 
to  the  appearance  of  the  eruption,  and  attaining  its  maximum  at  the  height 
of  the  efflorescence.  The  fever  may  continue  until  the  seventh  or  eighth 
day. 

"Seventh. — Eubella  is  seldom  accompanied  by  complications  or  fol- 
lowed by  sequels,  while  in  measles  complications  are  common  and  constitute 
the  most  serious  feature  of  the  disease.'^ 

In  studying  the  above  we  can  readily  see  that  measles  is  very  frequently 
mistaken  for  rubella.  Scarlet  fever  has  a  small  punctate  rash  very  uniform 
in  character.  The  temperature,  and  the  characteristic  throat  and  tongue 
Will  usually  differentiate  this  condition. 

Syphilis  is  frequently  mistaken  for  rubella,  but  the  absence  of  the 
characteristic  initial  lesion  will  aid  in  establishing  the  true  diagnosis.  Be- 
fore making  a  positive  diagnosis  we  should  see  that  our  patient  is  not  suffer- 
ing from  a  drug  eruption. 

Complications. — These  are  rarely  seen.  The  disease  is  so  benign  that  it 
rarely  leaves  any  after-effects.  Eecurring  rashes  have  been  described  by 
various  authors,  hence,  a  relapse  is  possible.  This  second  rash  does  not 
differ  in  character  from  the  first.  The  contagious  nature  of  this  condition 
has  been  well  established.  Hatfield  reports^  that  of  196  children  in  an 
asylum,  110  were  affected.  Corlett  believes  that  it  is  as  contagious  as 
measles,  but  the  contagium  retains  its  vitality  longer  and  hence  resembles 
scarlatina.  The  infectious  nature  of  this  disease  has  been  studied  by  Ed- 
wards, who  found  that  75  per  cent,  of  cases  in  an  epidemic  in  Philadelphia 
could  be  traced  to  infection  from  the  bunks  of  ships. 

Course. — Eubella  runs  a  mild  course.  Cases  seen  by  me  during  an 
epidemic  in  the  winter  of  1903-1904  remained  ill  about  three  to  four  days, 
rarely  five  days.  Some  authors  state  that  children  with  rubella  are  ill  one 
and  two  weeks. 

Pro^osis. — This  is  always  good.  With  good  sanitary  surroundings, 
aided  by  careful  diet,  recovery  always  takes  place. 

Treatment. — A  child  with  rubella  should  be  put  to  bed  and  kept  con- 
fined until  all  evidence  of  eruption  has  disappeared.  A  liquid  diet  should 
be  prescribed.  The  gastro-intestinal  tract  must  be  watched ;  the  bowels  and 
kidneys  assisted  if  necessary. 


^  Chicago  Medical  Examiner,  August,  1881. 


DUKE'S  DISEASE.  533 


Duke's  Disease  (Fourth  Disease). 

Many  authors  dispute  the  existence  of  a  fourth  disease^  and  maintain 
that  abortive  types  of  scarlet  fever  or  abnormal  types  of  rubella  are  the 
symptoms  observed  in  so-called  fourth  disease. 

The  existence  of  a  separate  exanthematous  eruption  has  been  brought 
before  the  profession  many  times.  As  early  as  1885  Filatow,  a  Russian, 
outlined  the  symptoms  of  a  fourth  disease. 

The  characteristic  symptoms  are  an  incubation  period  varying  between 
nine  and  twenty-one  days,  thus  resembling  rubella.  The  eruption,  according 
to  Duke,  is  of  an  erythematous  character  and  is  seen  on  the  face,  especially 
involving  the  skin  surrounding  the  mouth.  There  are  no  pharyngeal 
or  tonsillar  patches  visible.  The  tongue  does  not  show  the  characteristic 
strawbeiTy  appearance  of  scarlet  fever.  There  is  an  absence  of  fever  in 
most  cases,  and  the  active  symptoms  subside  after  two  or  three  days.  The 
lymph  nodes  in  the  neck,  axilla,  and  inguinal  region  are  palpably  swollen. 
Following  the  eruption  there  is  a  fine,  mealy  desquamation. 


.  CHAPTEE  VIII. 

MEASLES   (MORBILLI,  RUBEOLA). 

Measles  is  an  acute  eruptive  disease  associated  with  fever.  It  is 
caused  by  the  invasion  of  a  specific  micro-organism  the  character  of  which 
has  not  yet  been  definitely  determined. 

Bacteriology. — ^Anderson  and  Goldberger  have  settled  the  question  of 
the  period  of  infectivity  of  the  blood  in  measles.  By  inoculating  monkeys 
with  human  blood  from  patients  suffering  with  measles  they  find  that  the 
period  of  infection  is  greatest  Just  before,  and  for  about  twenty-four  hours 
after,  the  first  appearance  of  the  exanthem.  At  the  end  of  about  twenty-four 
hours  from  the  first  appearance  of  the  eruption,  the  infectivity  of  the  blood 
appeared  greatly  reduced  and  became  progressively  less  thereafter.  The 
virus  of  measles  belongs  to  the  ultra-microscopic  group.  Aronson  and  Som- 
merfeld  found  that  the  toxicity  of  the  urine  was  increased  in  measles. 
Thus,  if  2  c.c.  of  urine  from  a  case  of  measles  were  injected  intravenously 
into  a  guinea-pig,  the  pig  died  immediately  with  the  symptoms  of  anaphy- 
lactic shock,  or  else  became  extremely  ill.  While  this  same  toxicity  can  be 
found  in  children  suffering  with  the  fourth  disease,  and  also  with  the 
serum  disease,  no  such  toxicity  was  found  in  urine  from  cases  of  scarlet 
fever,  pertussis,  typhoid,  and  tuberculosis. 

Aronson  and  Sommerfeld  concluded  from  their  experiments  that  the 
urine  test  will  be  a  strong  differential  point  in  diagnosis  between  scarlet 
fever  and  measles.  It  would  be  important  to  note  that  the  virus  has  not 
been  demonstrated  in  the  mealy  desquamation. 

Etiology. — Measles  is  a  contagious  and  to  a  less  extent  an  infectious 
disease.  It  is  usually  communicated  direct  from  person  to  person.  Inter- 
mediate contagion  is  comparatively  rare.  Contagion  is  possible  three  or 
four  days  before  the  rash  appears  on  the  skin,  and  continues  until  desquama- 
tion has  ceased.  Children  differ  as  to  their  susceptibility,  some  contracting 
the  disease  by  very  short  exposure,  while  others  require  a  longer  and  more 
intimate  contact. 

The  disease  can  be  more  readily  conveyed  in  poorly  ventilated  or 
crowded  apartments,  schools,  and  kindergartens,  where  many  children  are 
intimately  associated. 

Period  of  Incubation. — The  period  of  incubation  ranges  between  nine 
and  fourteen  days,  the  average  being  eleven  days.  Some  authors^  give 
eighteen  to  twenty-one  days  as  the  period  of  incubation  when  measles  occurs 
a  second  time. 


^Graham:    Article  on  "Measles/'  Morrow's  "System  of  Dermatology,"   1894, 
vol.  iii. 

(584) 


PLATE  XXVII 


Earliest  Symjitom  of  ^Measles.  Can  be  seen  several  days  before 
eruption  on  body  appears.  Characteristic  bluisli-wliite  speck  on  a  rose- 
colored  background.  ^Minute  Avhite  dots  separated  from  one  anothei', 
best  seen  on  inside  of  cheek.  Tliey  are  very  dense  near  the  teeth;  more 
discrete  away  from  the  teeth.  Strong  snnlight  or  reflected  light  will 
aid  in  locating  them. 


MEASLES.  585 

In  New*  York  City  cases  of  measles  are  excluded  from  school  until  five 
days  after  the  appearance  of  the  rash,  at  which  time,  if  he  is  otherwise  well 
and  all  catarrhal  discharges  have  ceased  and  the  cough  has  disappeared,  he 
may  return.  Children  and  other  members  of  the  family  who  have  had  the 
disease  may  continue  in  school,  provided  the  quarantine  at  home  is  properly 
observed.  Children  and  other  members  of  the  family  who  have  not  had  the 
disease,  and  are  immediately  removed  to  another  residence,  may  return  to 
school  at  the  end  of  fourteen  days,  the  usual  limit  of  the  period  of  incubation. 

Pathology. — In  a  study  of  the  early  mucous  lesions  in  the  mouth 
Slawyk  found  that  the  epithelial  cells  were  thickened  and  in  some  in- 
stances had  undergone  fatty  degeneration,  No  specific  micro-organism  has 
been  found  in  the  lesions.  Frequently  there  is  a  tendency  to  the  formation 
of  ulcers,  which  extends  to  the  deeper  parts.  Unna  called  attention  to  the 
thrombosis  of  superficial  vessels  of  the  skin  in  a  severe  type  of  measles  re- 
sembling smallpox.  "When  gangrene  existed,  streptococci  were  always  pres- 
ent. Cornell  and  Babes  report  a  special  form  of  pneumonia  beginning  as  an 
interstitial  pneumonia  and  later  giving  rise  to  a  fibrinous  effusion  into  the 
alveoli.  It  involves  the  lymphatic  system,  the  interlobular  and  interalveolar 
tissue. 

The  toxic  effect  of  the  measles  virus  resembles  pathological  changes 
noted  in  diphtheria.  They  can  be  found  in  the  central  nervous  system.  No 
doubt,  the  toxin  generated  by  a  specific  organism  similar  to  that  of  the 
Loeffler  bacillus  found  in  diphtheria  causes  the  degenerative  changes. 

Symptoms. — Prodromal  Stage  or  Period  of  Invasion:  The  first  symp- 
toms are  those  of  an  ordinary  coryza,  sneezing,  dry  cough,  and  watering 
of  the  eyes  (lachrymation),  with  photophobia.  Moderate  fever,  temperature 
from  101°  to  102°  F.,  rarely  higher  during  the  first  day.  There  is  some- 
times vomiting. 

This  condition  lasts  about  three  days  and  is  followed  by  the  character- 
istic eruption.  This  eruption  is  first  seen  on  the  face  or  neck  on  the  morning 
of  the  fourth  day.  Very  young  infants  show  extreme  irritability  and  rest- 
lessness. The  tongue  is  covered  with  a  white  fur.  The  papillse  are  red  and 
swollen.  They  are  not  as  conspicuous  as  in  scarlet  fever.  There  is  intense 
dryness  and  thirst,  with  marked  anorexia,  and  usually  constipation. 

The  temperature  shows  great  variability.  Wunderlich,  Thomas  and 
von  Jurgensen,  who  have  studied  the  temperature  exhaustively,  state  that  it 
cannot  be  considered  characteristic,  owing  to  its  frequent  variations.  The 
temperature,  after  having  reached  102°  or  even  104°  F.,  will  on  the  second 
day  of  the  disease  drop  to  nearly  normal.  There  is  usually  a  morning  re- 
mission to  the  temperature.  The  temperature  in  a  characteristic  case  is 
sometimes  deceptive,  so  that  after  three  or  four  days  of  illness  there  may 
be  a  sudden  activity  of  all  symptoms  with  a  rise  of  temperature.  The  tem- 
perature frequently  reaches  105°  F. 


586  THE  INFECTIOUS  DISEASES. 

Early  Symptoms  of  Measles. — The  absence  of  the  thick  epidermic  cover- 
ing which  masks  the  first  pathological  manifestations  iri  the  skin  (exanthem) 
is  more  readily  seen  on  the  delicate  mucous  surfaces  (enanthem). 

The  enanthem  in  measles  has  long  been  known.  It  has  been  studied 
by  Willan,  in  1806;  by  Heim,  in  1812;  in  Diinglison's  "Cyclopsedia  of 
Practical  Medicine/'  in  1854;  by  Trousseau,  in  1866.  Niemeyer's  "Prac- 
tice of  Medicine,"  1876,  vol.  ii,  p.  528,  mentions  Rehn,  who  studied  an  erup- 
tion in  the  cheek,  gums,  lips,  and  fauces.  Rilliet  and  Barthez,  1854,  and 
Monti,  in  1873,  devote  considerable  attention  to  the  prodromal  enanthem  of 
measles. 

Flindt,  of  Denmark,  describes  it  at  length  in  the  "Sundheds-collegium," 
as  follows: — ■ 

"First  day  of  the  fever :    A  slight,  diffuse  erythema  of  the  throat. 

"Second  day  of  the  fever:  A  fairly  dark  redness  without  marked 
oedema  of  posterior  pharyngo-palatine  arch  and  tonsils,  which  on  the 
anterior  palatine  arch  (arcus  glosso-palatinus)  and  velum  palati  is  some- 
what less  deep  in  color  and  of  an  irregularly  diffused  or  mottled  appearance. 
On  the  evening  of  the  second  day  of  the  fever  the  mucous  surfaces  of  the 
tonsils,  and  the  posterior  palatine  arch,  have  undergone  but  little  or  no 
change,  appearing  as  a  uniformly  red  erythema,  with  slight  oedema.  On 
the  anterior  surface  of  the  soft  palate,  and  the  posterior  part  of  the  hard 
palate,  as  well  as  occasionally  on  the  remaining  normal  mucous  surfaces,  a 
distinct  enanthema  appears.  The  lesions  are  round  or  irregular  in  shape,  of 
a  bright-red  color,  having  an  ill-defined  margin,  with  little  or  no  elevation 
at  this  time  above  the  surrounding  surface.  They  range  from  a  pin-head 
to  a  lentil  in  size,  and  occur  singly,  or  are  scattered  irregularly  over  the 
surface.  In  places  there  is  a  tendency  for  the  lesions  to  cluster  in  groups 
and  to  become  blended. 

"They  acquire  a  peculiar  appearance  on  account  of  numerous  small, 
white,  glisteniag  points  (simulating  minute  vesicles),  which  occupy  the 
middle  of  the  small,  red  macules.  These  manifestations  in  the  macules  are 
irregularly  grouped.  One  can  see  and  feel  the  minute  vesicles  elevated  above 
the  surrounding  areas.  The  palpebral  conjunctiva  is  hypersemic  in  its 
entire  extent.  Besides  the  reticular  and  macular  reddening  of  the  con- 
junctiva, which  is  due  to  the  disposition  of  the  conjunctival  vessels,  there  are 
also  small,  glistening,  miliary  elevations  similar  to  the  elevations  in  the 
palate. 

"Third  day  of  the  fever:  The  mucous  surfaces  of  the  buccal  cavity, 
which  up  to  this  time  have  been  only  slightly  hypersemic,  are  now  found  to 
be  invaded  by  the  lesions  previously  described.  These  latter  are  strongly 
marked  over  the  entire  anterior  surface  of  the  velum  palati,  the  glosso- 
palatine  arch,  and  usually  also  over  the  contiguous  two-thirds  of  the  hard 
palate.    The  red  spots  are  sometimes  very  numerous,  at  other  times  isolated, 


MEASLES.  587 

and  again,  by  blending,  they  form  irregular  figures  of  a  stronger  red  than 
previously  seen.  Here  and  there  a  faint  appearance  of  the  previously 
described  vesicle-like  formations  is  seen  projecting  above  the  surrounding 
surface.  On  the  other  hand,  they  may  also  be  found  on  the  apparently 
normal  mucous  membrane.  Similarly  grouped  spots  with  whitish  vesicles 
now  also  appear  on  the  inner  surface  of  the  cheeks,  especially  on  the  part 
opposite  the  juxtaposition  of  the  upper  and  lower  molar  teeth. 

"As  a  rule,  the  gums  and  the  inner  surface  of  the  lips  retain  their  nor- 
mal color,  or  at  most  are  only  slightly  hypersomic.  It  is,  indeed,  seldom  that 
the  eruption  appears  on  these  parts.  The  tonsils  and  both  pharyngo- 
palatine  arches  still  remain  red. 

''The  palpebral  conjunctiva  retains  its  deep-red  color,  but  no  spots  are 
visible,  excepting  the  minute  vesicles  previously  described.  At  this  time 
the  eruption  breaks  forth  on  the  skin.  On  the  evening  of  the  third  day 
there  is  little  or  no  change  perceptible. 

"Fourth  day  of  the  fever:  On  the  palate  and  inner  surface  of  the 
cheeks  the  spots  stand  out  prominently,  while  in  many  places  there  is  a 
tendency  to  merge  by  enlargement  of  the  individual  lesions,  and  on  the 
surfaces  last  invaded  they  are  more  copious  than  ever.  The  conjunctival 
exauthem  is  now  disappearing.  On  the  evening  of  this  day  there  is  no 
change  noted. 

"Fifth  day  of  the  fever :  The  exanthem  in  the  buccal  cavity  is  more 
marked  than  heretofore.  Frequently  at  this  time  there  appear  faint-reddish 
spots  on  the  mucous  surfaces  of  the  lips,  even  extending  to  the  exposed 
cutaneous  margin.  On  the  gums  they  are  seldom  present  and  never  distinct. 
The  hypergemia  of  the  posterior  fauces  remains  unchanged.  The  skin 
exanthem  begins  to  fade,  and  the  temperature  falls. 

"Sixth  day  of  the  fever :  The  exanthem  of  the  mucous  surfaces  is  no 
longer  visible,  except  a  slight  diffuse  redness  of  the  palate  and  the  inner 
surface  of  the  cheeks.     Fever  ends." 

This  characteristic  enanthem  is  seldom  absent.  Slawyk^  found  it 
present  in  90  per  cent,  of  all  cases  examined. 

Koplik  described  these  symptoms-  and  to  him  belongs  the  credit  of 
having  popularized  the  enanthem.  It  is  generally  known  as  Koplik's  sign. 
The  spots  are  best  seen  on  the  inside  of  the  cheeks  opposite  the  molar 
teeth,  although  I  have  seen  them  very  clearly  defined  on  the  mucous  mem- 
brane of  the  upper  lip  corresponding  to  the  incisors. 

The  patient  must  be  examined  in  a  strong  sunlight  or  with  a  good 
electric  light.    A  3^e]]ow  gaslight,  for  instance,  is  very  unsatisfactory. 

Differential  Value  of  tliis  Sign. — This  enanthem  is  of  great  value 
in  diiferentiating  measles  from  other  exanthemata,  notably,  however,  from 


^Slawyk:     Deut.  med.  Woch.,  April  28,  1898. 
^Archives  of  Pediatrics,  December,  1896;  Medical  Record,  1898. 


588  THE  INFECTIOUS  DISEASES. 

antitoxin  rashes,  drug  eruptions,  and  eruptions  associated  with  toxaemia 
from  gastric  fevers. 

Period  of  Efflorescence  {Eruptive  Stage). — ^The  eruption  usually  ap- 
pears on  the  fourth  day  of  the  disease.  Sometimes  it  appears  as  early  as  the 
third  and  sometimes  as  late  as  the  fifth  day.  The  first  spots  appear  on  the 
forehead  or  the  temples,  behind  the  ears,  and  on  the  sides  of  the  neck. 
Later,  spots  appear  about  the  eyes,  mouth,  and  chin.  When  the  rash  is  at 
its  height  then  a  crescentic  character,  first  described  by  Willan,  will  be 
noticed.  The  constitutional  disturbances  increase  in  severity.  The  cough 
is  more  pronounced  and  there  is  a  decided  interference  with  the  respiration. 
Nosebleed  is  quite  frequent.  Constipation  is  usually  followed  by  very  loose 
bowels. 

The  Rash. — The  rash  is  of  a  dark-red,  sometimes  a  purplish,  color,  of  a 
round,  oval  or  irregular  shape.  The  skin  between  the  rash  remains  intact, 
although  the  face  has  a  puffy,  oedematous  appearance.  The  eruption  extends 
over  the  trunk  and  extremities,  including  the  palms  and  soles,  the  arms 
and  legs,  the  forearms  and  legs  being  the  last  to  become  affected. 

When  the  rash  reaches  its  height  the  constitutional  symptoms  subside. 
It  is  not  infrequent  to  see  a  normal  temperature  two  days  after  the  rash  has 
completely  covered  the  body.  In  some  instances  there  is  a  crisis,  although 
the  usual  rule  is  for  the  temperature  to  fall  gradually  by  lysis.  A  sub- 
normal temperature  frequently  follows  and  accompanies  the  period  of  con- 
valescence and  until  the  patient  is  normal. 

The  catarrhal  symptoms  continue  to  increase  in  severity  with  the  devel- 
opment of  the  rash. 

There  are  moist  rales  heard  on  auscultation.  The  sputum  as  well  as  the 
nasal  discharge  becomes  sero-purulent.  A  bronchitis  or  a  pneumonia  should 
be  suspected,  if  the  respiration  is  exaggerated.  The  pulse-respiration  ratio 
will  he  found  of  great  value  in  diagnosing  latent  pneumonia.  The  urine 
will  show  the  excess  of  urates,  and  sometimes  transitory  albuminuria  or 
hyaline  casts  may  be  found.  The  diazo  reaction  is  sometimes  noted,  but  it 
does  not  teach  us  anything  of  value  in  either  the  diagnosis  or  prognosis. 
This  stage  of  the  disease  rarely  lasts  more  than  from  four  to  six  days. 

Stage  of  Desquamation,  or  Convalescent  Period. — The  eruption  on  the 
skin  of  the  face,  neck,  and  upper  part  of  the  chest  fades  and  there  is  a  slight, 
branny  desquamation.  This  is  less  marked  than  in  scarlet  fever,  and  is  so 
fine  on  the  trunk  and  extremities  that  it  may  be  unobserved.  It  is  best  seen 
on  the  sides  of  the  nose,  temples  and  chin.  Large,  flaky  scales  are  rarely 
met  with  in  measles.  After  the  eruption  disappears,  a  certain  amount  of 
pigment  remains  for  a  week  or  two  where  the  rash  existed. 

Atypical  or  Anomalous  Conditions. — Certain  symptoms  of  normal 
measles  vary  in  different  epidemics,  although  the  majority  of  cases  present 
distinct  clinical  features.    Predisposing  factors,  such  as  rickets  and  scurvy. 


MEASLES.  589 

possibly  tuberculosis,  will  frequently  alter  the  type  of  the  disease  or 
modify  the  symptoms.  Edgar^  reports  an  epidemic  of  423  cases  in  which 
123  adhered  to  the  regular  type. 

Abortive  Type. — We  occasionally  see  a  child  with  catarrhal  symptoms 
and  an  eruption  lasting  but  one  or  two  days,  after  which  the  child  is  as 
well  as  ever.  Such  cases  will  frequently  baffle  the  physician  because  of  the 
irregular  course.    These  cases  belong  to  the  abortive  type. 

Typhus  Fever. — Typhus  fever  frequently  resembles  measles.  There 
is  an  absence  of  the  catarrhal  symptoms  common  to  measles.  The  eruption 
is  more  marked  on  the  body,  less  marked  on  the  face.  In  typhus  there  are 
severe  nervous  and  cerebral  manifestations  which  rarely  exist  in  measles. 

In  measles  the  eruption  is  macular  or  papular  and  arranged  in  irreg- 
ular, crescentic  groups,  and  begins  on  the  face. 

In  typhus  the  eruption  is  rarely  seen  on  the  face  and  is  petechial  in 
character. 

Anaphylaxis.^ — Morbilliform  rashes  frequently  follow  the  ingestion  of 
certain  albuminous  foods,  so  that  some  children  will  be  covered  with  an 
eruption  resembling  measles  when  partaking  of  eggs  or  meat.  Other  chil- 
dren will  have  a  severe  eruption  after  an  injection  of  horse-serum.  This 
subject  has  been  described  in  detail  in  the  chapter  on  "Diphtheria." 

The  characteristic  feature  of  an  anaphylactic  reaction  (morbilliform 
type)  is  the  absence  of  the  catarrhal  symptoms.  There  is  no  conjunctivitis 
nor  cough,  which  latter  always  accompanies  true  measles. 

The  temperature  rises  the  day  preceding  the  eruption,  and  returns  to 
normal  on  the  appearance  of  the  exanthem. 

Mild  Forms. — Measles  may  be  present  without  catarrhal  s3rmptoms.  In 
such  cases  fever  may  be  slight  or  absent.  In  other  cases  the  catarrhal 
symptoms  are  severe,  while  the  cutaneous  exanthem  is  almost  wholly  absent 
(morbilli  sine  morbillis).  Such  cases  might  readily  escape  notice  unless 
they  partake  of  a  series  during  an  epidemic  in  which  both  the  mild  and 
the  severe  type  are  found. 

Relapsing  Form,  or  Second  Attach. — A  relapse  is  said  to  occur  in  rare 
instances  after  the  exanthem  has  disappeared.  When  the  second  rash 
appears  there  is  a  return  of  fever  and  also  the  other  constitutional  symp- 
toms. Eecurring  measles  is  often  a  very  serious  matter,  owing  to  the 
already  weakened  state  resulting  from  the  first  invasion. 

Corlett  doubts  the  so-called  relapses  and  believes  that  they  are  due  to 
a  direct  reintoxication  by  the  specific  virus. 

Severe  or  Malignant  Forms. — ^Malignant  measles  is  that  form  in  which 
there  is  a  very  high  fever,  rapid  pulse,  labored  breathing,  and  great  prostra- 

^Can.  Med.  Record,  December,  1892. 
'  See  "Anaphylaxis  in  Diphtheria." 


590 


The  infectious  diseases. 


tion.  The  fatal  issue  most  frequently  occurs  on  the  second  day  of  the 
exanthem.  We  frequently  meet  with  a  typhoidal  or  a  toxic  form  in  which 
the  symptoms  are  of  a  most  malignant  character.  The  mouth  becomes 
parched  and  the  tongue  brown  and  dry,  resembling  a  typical  typhoidal  cpn- 
dition. 

The  bowels  are  loose  and  the  quantity  of  urine  diminished.  Convul- 
sions resulting  from  the  general  toxsemia  are  very  common.  It  is  usually 
fatal  and  rarely  ends  in  recovery.  Where  there  is  severe  respiratory  dis- 
turbance, with  difficult  breathing,  it  is  called  the  suffocative  form.  In  this 
form  we  have  principally  cough  and  expectoration  with  severe  dyspnoea. 

The  patient  is  cyanotic.  Mucous  rales  are  heard  early  in  the  disease, 
and  it  not  infrequently  ends  in  a  broncho-pneurnonia. 

Hcemorrhagic  forms,  known  as  the  black  measles,  are  frequently  de- 
scribed. The  mild  form  of  hsemorrhagic  measles  has  been  described  by 
various  authors.  Edgar  reports  200  cases  out  of  423,  or  47  per  cent,  of  the 
hsemorrhagic  form.  Holt  found  it  in  5  per  cent,  of  his  cases.  The  cutane- 
ous exanthem  assumes  a  dark  bluish  or  purplish  tint,  which  gradually  deep- 


Table  No.  59. — Showing  503  Cases  of  Measles  and  Qomplications,  Treated  in  the  Eiverside 
Hospital,  New  York  City,  During  the  Months  of  January  to  July,  Inclusive. 


No.  of  Cases. 

Uncompli- 
cated Measles. 

Measles 

and 

Diphtheria. 

Measles 

and 

Pneumonia. 

Measles,  Scar- 
let Fever  and 
Diphtheria. 

Measles  and 
Scarlet  Fever. 

1904 

Gases 

Deaths 

Cases 

Deaths 

Cases 

Deaths 

""ases 

Deaths 

Cases 

Deaths 

Cases 

Deaths 

Jan. 

34 

4 

31 

1 

2 

2 

1 

1 

Feb. 

70 

8 

62 

1 

7 

6 

1 

1 

Mar. 

133 

14 

111 

2 
0 

9 

6 

4 

4 

2 

1 

7 

1 

Apr. 

103 

15 

84 

8 

8 

10 

7 

1 

0 

May- 

106 

16 

77 

2 

13 

4 

13 

8 

1 

1 

2 

1 

June 

37 

8 

23 

0 

7 

3 

1 

30 

7 

5 

4 

July 

20 

5 

12 

0 

3 

5 

Total 
Cases 

503 

400 

49 

41 

4 

9 

Total 
Deaths 

70 

6 

30 

2 

2 

MEASLES. 


591 


ens  as  the  process  continues,  to  a  bluish-black  color.  Frequently  the  whole 
body  shows  a  tendency  to  bleed.  Thus  the  mucous  surfaces  are  implicated, 
giving  rise  to  epistaxis,  bleeding  from  the  gums,  dysentery  stools  and 
haemorrhages  from  the  genito-urinary  tract.  Where  a  tendency  to  haemor- 
rhage exists,  as  in  haemophilic  subjects  (bleeders),  they  are  especially  predis- 
posed to  the  hemorrhagic  form. 


Fig.  ISO. — A  Case  of  ]\Ia]ignant  Measles,  complicated  by  Diphtheria  and 
ending  with  Empyema.  Male  child,  3  years  old.  Septic  from  beginning. 
Fatal  termination.  Seen  in  my  service  at  Riverside  Hospital,  New  York 
City,     (Original.) 

Complications. — Pulmonary:  There  seems  to  be  a  predisposition  to 
pulmonary  disease,  commencing  with  a  bronchial  catarrh,  especially  in  those 
children  with  feeble  resisting  power.  The  inflammatory  condition  extends 
into  the  smaller  ramifications  of  the  bronchial  tubes,  causing  capillary 
bronchitis.  When  this  occurs  it  should  be  viewed  with  alarm.  The  child 
shows  dyspnoea  and  ad3Tiamic  symptoms,  owing  to  difficult  oxygenation. 


592 


THE  INFECTIOUS  DISEASES. 


The  Larynx. — One  of  the  most  frequent  and  fatal  complications  met 
with  in  children  is  laryngitis.    This  may  be : — 

(a)  Spasmodic. 

(h)  Phlegmonous. 

(c)  Membranous. 

The  last  named  complication  is  the  one  most  frequently  met  with,  espe- 
cially in  institutions.  It  is  most  common  during  the  eruptive  stage  as  early 
as  the  third  or  fourth  day.  The  symptoms  are  the  same  as  those  met  with 
in  laryngeal  diphtheria  accompanied  by  stenosis  of  the  larjmx. 

The  Klebs-LoefQer  bacillus  is  sometimes  found  on  bacteriological  ex- 
amination of  the  pseudo-membrane.  It  can  be  found  in  6  to  10  per  cent,  of 
all  cases  of  membranous  laryngitis. 


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Fig.  190. — Temperature  Chart  from  a  Case  of  Measles  Complicated  by 
Broneho-pneumonia.  Seen  during  my  ser^dce  at  the  Riverside  Hospital,  New 
York  City.     (Original.) 

Broncho-pneumonia. — This  is  the  most  frequent  and  the  most  fatal 
complication  of  measles.  Houl^  found  it  in  one-fifth  of  all  of  his  cases.  In 
the  Xursery  and  Child's  HosjDital  of  Xew  York,  Holt  observed  it  in  -±0  per 
cent,  of  all  cases.  This  infection  can  invariably  be  traced  to  the  presence  of 
various  organisms  of  which  the  pneumococcus  of  Friediander,  and  the 
micrococcus  of  Friinkel  play  a  conspicuous  role. 

There  is  marked  retraction  of  the  chest  in  addition  to  the  usual  signs 
of  pneumonia.  The  physical  examination  shows  widely  disseminated  sub- 
crepitant  rales  which  soon  give  way  to  definite  resonance,  bronchial  breath- 
ing, and  fine  crepitations.  In  j'oung  children  its  onset  is  acute,  with  rapid 
pulmonary  congestion,  and  it  usually  terminates  fatally  within  two  or  three 


*  Wien.  klin.  Rund.,  1897,  vol.  xi,  p.  833. 


MEASLES. 


593 


days.    When  tlie  condition  extends  over  a  more  subacute  course,  it  may  lead 
to  caseous  pncuinonia  or  pulinouary  tuberculosis. 

Case  I.  Kate  A.,  aged  twenty-one  months.  Child  was  admitted  to  the  Riverside 
Hospital  August  25,  1904,  in  fairly  good  condition,  with  temperature  104°  F.,  pulse 
136,  respiration  3G.  Sick  since  August  22d.  Child  had  a  moderately  severe  cough  on 
admission.  On  August  2Gth  cough  increased  in  severity,  breathing  short,  rapid  and 
labored. 

Physical  examination  showed  only  a  few  coarse  rales  at  upper  part  of  chest 
posteriorly,  with  slight  dullness,  but  no  bronchial  breathing. 


i9.oA. 

1 

fiu 

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29 

30 

31 

1 

2 

3 

4 

Cent. 

Fahr. 

AM>M 

am:pm 

AMiPM 

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39°  ~ 

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5 

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u: 

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lini-plraticnia 
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It: 

Fig.  191. — Temperature  Chart  from  a  Case  of  Measles  Complicated  by 
Broncho-pneumonia.     Seen  during  my  service  at  the  Eiverside  Hospital, 

New  York  City.     (Original.  )i 


Well-marked  dullness  over  the  right  base  posteriorly,  with  bronchial  voice  and 
breathing.  Left  base  behind  gave  slight  dullness  with  many  coarse  rales.  No  bron- 
chial bi'eathing. 

On  August  2Sth,  pleuritic  friction  sounds  over  right  base  posteriorly. 

On  August  31st,  percussion  gave  marked  dullness,  almost  flatness  over  this 
area,  extending  slightly  above  the  infeiior  angle  of  right  scapula.  Over  this  area, 
marked  bronchial  voice  and  breathinjr. 


'T  am  indebted  to  Drs.  Alfred  Helge.son,  Bruno  Horwicz,  and  Wm.  Ogden  Lord  for 
clinical  histories,  charts,  and  statistics. 


594 


THE  INFECTIOUS  DISEASES. 


On  September  Ist^  bloody  serum  obtained  upon  aspiration. 

On  September  3d,  serum  obtained  by  aspiration,  bloody  with,  slight  turbidity. 
General  condition  continued  the  same  up  to  September  9th.  On  this  day  a  drop  in 
the  temperature  from  102°  to  97.6°  F.  occurred.  Child  appeared  brighter,  slept  well 
and  has  a  good  appetite. 

During  the  last  two  days,  fluctuations  in  temperature  have  occurred,  ranging 
from  98°  to  101°  F.   (evening  rise). 

This  fluctuation  of  temperature  continued  up  to  September  14th.  On  this  date 
there  was  an  evening  rise  to  99°  F.  only,  and  since  then,  the  highest  rise  has  been 
99V5°  F.  The  pulse  has  improved  much  in  quality.  Respirations  have  gradually  di- 
minished in  frequency.  The  child  was  aspirated  on  the  13th,  but  no  pus  or  serum 
was  obtained.  Dullness  was  diminished  over  right  base  posteriorly  and  bronchial 
breathing  was  present  only  over  a  small  area  at  base  of  right  lung.  Child  at  present 
sits  up,  has  good  aj^petite,  and  sleeps  well. 

Case  II.  L.  Z.,  age  eight  months.  Admitted,  to  the  Riverside  Hospital  on  August 
29th,  having  been  ill  since  the  21st.  Upon  admission  showed  characteristic  symptoms 
of  broncho-pneumonia  with  temperatufe  101.4°  F.,  pulse,  150;  respiration,  56.  Upon 
examination,  dullness  was  present  over  right  base  behind,  with  bronchial  voice  and 
breathing.  Many  coarse  rales  were  heard  over  both  lungs  behind  as  well  as  in  front. 
There  was  a  pleuritic  friction  sound  over  the  consolidated  area.  No  signs  of  effusion. 
Child  improved  rapidlj^  and  upon  September  3d,  the  bronchial  breathing  had  disap- 
peared and  only  signs  were  coarse  rales  over  both  bases  behind.      Recovery, 

Otitis  Complicating  Measles.^ — A  very  frequent  sequela  is  acute  otitis. 
If,  after  several  days  of  apparent  convalescence  the  child  is  irritable,  restless 
at  night  and  feverish,  and  cries  continuously,  a  careful  examination  of  the 
ears  should  be  made.  As  a  rule  our  attention  is  first  directed  to  this  con- 
dition after  the  cavity  of  the  middle  ear  is  filled  with  the  discharge,  and 
there  is  a  spontaneous  discharge  of  pus. 

Siegfried  Weiss^  calls  attention  to  the  method  of  prophylaxis  in  this 
condition.  He  believes  that  with  good  care  we  can  prevent  and  abort  this 
complication.  Tobeitz  believes  that  in  measles  we  are  dealing  with  a  pri- 
mar}^  enanthematous  disease  of  the  middle  ear. 

In  a  post-mortem  study  of  95  cases,  pathological  changes  affecting  the 
ear  showed  the  destructive  tendency  due  to  the  disease  itself. 

Tobeitz  found  that  86  per  cent,  of  fatal  cases  of  measles  showed  ear  com- 
plications. Bezold  in  a  study  of  18  fatal  cases  of  measles  noted  ear  disease 
in  17,  or  about  95  per  cent.  Weiss  studied  112  cases  in  which  there  were 
ear  complications,  and  after  careful  prophylactic  treatment  he  had  only  6.6 
per  cent,  of  ear  complications.  Weiss's  prophylactic  method  consists  in  ap- 
plying a  1  per  cent,  yellow  precipitate  ointment  on  a  sterile  swab  to  the 
nostrils.  By  this  method  he  removes  the  dried  and  fluid  secretions  from  the 
nose  mechanically.  Another  method  of  Weiss'  consists  in  allowing  1  or  2 
drops  of  ^/a  per  cent,  nitrate  of  silver  solution  to  drop  into  the  nostril.    In, 


^  Read  chapter  on  "Otitis." 

^  Wiener  Medieinische  Wochenschrift,  No.  52,  1900. 


MEASLES. 


595 


this  manner  he  believes  we  can  destroy  the  specific  infectious  material. 
Hayek  has  long  advocated  this  method  in  the  treatment  of  chronic  rhinitis 
in  children.  In  using  the  salve  or  the  silver  nitrate  solution  Weiss  iound 
that  if  it  was  applied  three  or  four  times  a  day,  the  percentage  of  compli- 
cations was  greatly  reduced. 


Table  No.  60. — Measles  Stat  sties  Showing 
Ear  Complications,  Riverside  Hospital. 


1904. 

Number  of 
Cases. 

Measles  and 
otitis. 

January 

31 

6 

February 

74 

11 

March 

127 

10 

April 

101 

14 

Total 

333 

41 

Empyema. — Empyema  is  occasionally  met  with  during  the  course  of 
measles.  As  there  seems  to  be  a  decided  tendency  to  suppurative  formations, 
it  is  well  to  inspect  the  thorax  and  be  sure  that  we  can  exclude  empyema. 
This  should  be  borne  in  mind  if  cough  exists  associated  with  fever.  I  have 
seen  empyema  complicating  measles  in  about  3  per  cent,  of  my  cases.  When 
the  exploratory  puncture  shows  pus  the  treatment  is  the  same  as  that  given  in 
the  chapter  on  "Empyema." 

The  Eyes. — Severe  inflammatory  and  destructive  changes  are  met  with 
in  measles.  Abscesses  of  the  conjunctiva  or  keratitis,  resulting  in  ulceration 
of  the  cornea,  are  sometimes  seen.  In  other  cases  it  may  extend  to  the 
antrum  or,  if  the  mastoid  cells  are  involved,  it  can  result  in  meningitis, 
cerebral  abscess,  or  pyaemia.  In  very  young  children  the  petromastoid 
suture,  which  at  this  time  is  still  patent,  allows  free  access  of  pus  into  the 
cranial  cavity  from  the  middle  ear.  Not  infrequently  this  condition  leads 
to  actual  deafness. 

Immunity. — One  attack  of  measles  usually  confers  immunity  for  life. 
Second  attacks  are,  however,  possible,  and  third  attacks  have  also  been  re- 
ported as  instances  of  rare  conditions. 

Measles  is  rarely  seen  in  infants  under  1  year.  Mayr  observed  that  of 
10  nurslings  exposed  to  measles,  only  one  contracted  the  disease.  I  have 
rarely  met  with  infectious  diseases  in  healthy  breast-fed  infants.  There 
seems  to  he  some  antitoxic  property  conveyed  to  the  nursing  infant  through 
the  serum  contained  in  the  hreast-jnilJc  of  its  mother. 


596  THE  INFECTIOUS  DISEASES. 

.  At  the  Eiverside  Hospital  I  have  seen  nursing  infants,  in  the  measles 
wards,  that  liad  been  exposed  and  did  not  contract  the  disease. 

Immunity  can  be  conve3'ed  by  a  mother  who  has  had  measles,  through 
her  milk,  but  how  long  this  immunity  lasts  remains  still  to  be  investigated. 

Diagnosis. — An  ordinary  cold  with  coryza,  as  met  with  in  influenza,  is 
sometimes  confusing.  Mistakes  will  occur  unless  we  are  careful  to  note  the 
enanthem  which  is  absent  in  influenza.  The  rise  of  temperature  is  less 
marked  in  influenza  than  in  measles. 

The  diazo  reaction  is  sometimes  observed  in  cases  of  measles.  By  its 
presence  we  cannot,  however,  diagnose  measles. 

Drug  Eruptions. — Some  eruptions  resembling  measles  are  caused  by 
quinine  and  antipyrin.  The  internal  use  of  chloral  is  sometimes  followed 
by  an  eruption.     Cubebs  and  copaiba  give  an  eruption  simulating  measles.^ 

Bites  of  insects,  especially  bedbugs,  fleas,  and  mosquitoes,  sometimes 
produce  an  eruption  which  resembles  measles.  As  there  is  no  febrile  dis- 
turbance or  any  enanthem  the  differential  diagnosis  is  easily  made.  The 
injection  of  antitoxin  and  antistreptococcic  serum  sometimes  produces  an 
eruption  which  is  morbilliform  in  character. 

Course. — As  a  rule  three  weeks  should  elapse  before  a  case  of  measles 
is  permitted  to  return  to  healthy  children.  The  quarantine  should  be  ex- 
tended over  this  length  of  time.  This  applies  to  institutions  as  well  as  to 
private  families.  Isolation  should  be  continued  if  a  case  suffers  from  any 
complication  associated  with  the  primary  measles.  In  other  words,  measles 
otitis,  measles  vaginitis,  or  any  other  complication,  requires  isolation. 

Prognosis. — When  reasonable  care  is  taken,  then  this  is  one  of  the  least 
fatal  of  infectious  diseases.  The  vital  point  consists  in  guarding  the  patient 
against  unnecessary  exposures  and  attending  to  all  functional  disturbances. 
With  proper  attention  to  the  diet  and  symptomatic  treatment  when  neces- 
sary, there  should  be  little  or  no  trouble  experienced.  If  the  fever  declines 
after  the  full  development  of  the  exanthem,  the  prognosis  is  good. 

If  croup  and  diphtheria  complicate  measles,  then  the  prognosis  is  al- 
ways grave.  Broncho-pneumonia  is  usually  fatal  in  one-third  to  one-half 
of  all  cases.  Sometimes  a  broncho-pneumonia  will  be  followed  by  tuber- 
culosis. Diarrhoea  with  or  without  bloody  stools  should  always  be  looked 
upon  as  a  serious  complication. 

Treatment. — In  the  treatment  of  measles  certain  rules  should ,  in- 
variably be  followed : — 

(a)  Hygienic. 

(h)  Dietetic. 

(c)  Medicinal. 

Hygienic  Treatment. — The  temperature  of  the  room  should  always  be 


P.  A.  Morrow:      "Drug  Eruptions,"  New  York,  1887. 


MEASLES.  597 

uniform,  no  less  than  G8°  F.  and  never  more  than  74°  F.  Modern  clinicians 
assert  that  the  former  method  in  vogue,  of  bundling  up  the  body  and  keeping 
the  air  of  the  room  very  hot,  produces  a  certain  amount  of  susceptibility  to 
respiratory  diseases.  In  this  manner  we  invite  complications  rather  than 
prevent  them.  The  body  of  the  child  may  be  sponged  with  tepid  or  warm 
water,  and  fresh  linen  can  be  given  every  day. 

Overheated  rooms  cause  more  trouble  during  treatment  of  respiratory 
affections  than  any  other  factor. 

Light  of  the  Room. — Careful  observers  have  noted  that  the  light  in 
the  room  has  absolutely  nothing  to  do  with  the  eyes.  Owing  to  the  in- 
flammatory state  of  the  eyes,  there  is  a  normal  photophobic  condition.  •  No 
one  would  think  of  putting  a  child  in  the  beginning  of  measles  in  a 
glaring  sunlight,  but  rather  with  its  back  to  the  light.  At  the  measles  pa- 
vilion in  Berlin,  under  the  supervision  of  Professor  Baginsky,  the  hygienic 
conditions  are  perfect.  Plenty  of  fresh  air  is  admitted  and  also  light.  I 
have  frequently  had  the  pleasure  of  making  rounds  in  the  wards  of  this 
pavilion  with  Professor  Baginsky,  and  noted  the  above-named  conditions. 
We  do  not  darken  the  windows  in  the  measles  wards  at  the  Riverside  Hos- 
pital of' New  York  City,  and  the  hygienic  conditions  regarding  fresh  air  and 
fresh  linen  have  been  excellent  during  my  term  of  service  there. 

Dietetic  Treatment. — We  must  not  forget  that  in  all  febrile  conditions 
the  digestive  function  is  impaired.  The  diet  must  be  so  regulated  that  there 
is  proper  assimilation.  If  subnormal  conditions  prevail,  we  must  order  a 
smaller  quantity  of  food  and  allow  a  longer  interval  between  feedings. 

A  baby  receiving  pure  milk  should  receive  one-half  milk  and  one-half 
oatmeal  water,  and  if  it  has  been  fed  every  three  hours  when  in  good  health, 
then  it  is  wise  to  try  to  feed  every  four  or  five  hours  during  the  febrile  stage 
of  measles.  An  important  point  to  remember  is  that  liquids  are  an  im- 
portant part  of  the  treatment.  Soups,  acidulated  waters,  and  carbonated 
waters  are  grateful  and  indicated.  Orangeade  and  lemonade  are  grateful, 
especially  to  relieve  thirst.  If  the  child  is  older  and  has  been  fed  on  solid 
food  when  in  health,  then  all  solids  should  be  discontinued  and  liquid  food 
substituted.     Water  should  be  given  in  large  quantities. 

Medicinal  Treatment. — If  the  eruption  is  tardy  in  appearing  then  a 
mustard  foot-bath,  using  a  tablespoonful  of  mustard  in  a  foot-tub  of  warm 
wffter,  100°  F.,  and  adding  warm  water  gradually  until  the  temperature  is 
about  105°  F.,  will  frequently  hasten  the  appearance  of  the  rash.  This  is 
as  hot  as  the  child  can  stand  it  for  a  few  minutes.  If  there  is  a  general 
depression  of  the  vital  powers,  then  give  spir,  minderems,  a  teaspoonful 
every  hour,  until  perspiration  is  active.  This  will  also  frequently  hasten 
the  appearance  of  the  rash.  One  of  my  favorite  drugs  is  tincture  of  aconite, 
in  l-drop  doses,  if  the  fever  is  very  high. 


598  THE  ESTFECTIOUS  DISEASES. 

Pneumonia  requires  the  same  care  and  treatment  as  if  it  were  not  a 
complication  or  a  sequela  to  this  disease.     (See  chapter  on  "Pneumonia.^') 

Diphtheria  calls  for  the  same  treatment  as  if  it  was  not  associated  with 
measles. 

Immunity  from  Diphtheria. — An  injection  of  300  to  500  antitoxin 
units  will  confer  immunity  from  diphtheria  in  a  case  of  measles. 

The  urine  must  be  frequently  examined  for  a  possible  nephritis  and 
treated  accordingly. 

Convulsions  frequently  usher  in  the  disease  and  should  be  very  care- 
fully attended  by  rest,  sinapisms,  enemata  of  chloral,  and  possibly  a  few 
leeches  to  the  neck. 

Epistaxis  is  usually  an  early  but  passing  symptom,  but  if  persistent, 
it  should  be  treated  on  general  principles  and  the  cause  looked  into.  The 
congestion  during  an  attack  of  measles  has  frequently  excited  an  otherwise 
quiet  polypus  to  activity  and  caused  alarming  haemorrhages. 

Tor  the  relief  of  the  cough  I  usually  give : — 

IJ  Ammon.    bromid 9  ij  3.00 

Syr.  liquorit 5j      or      25.00 

Decoct,    altlise ad  Sij  50.00 

M.     Teaspoonful  every  hour,  for  a  child  1  year  old,  until  relieved. 

For  a  child  2  years  old: — 

IJ  Codeine   2  grains 

Sacch.    alb 1  V2  drachms 

M.  Divide  in  chart  Xo.  X.  Sig. :  One  powder  every  two  hours  until  cough  is 
relieved. 

Summary  of  Treatment. — Give  the  child  excellent  hygiene — afresh  air — 
protect  the  body  with  clean  linen.  Guard  against  draughts.  Isolate  the 
patient. 

Do  not  give  solid  food;  liquid  diet  only,  soups,  broths,  milk,  butter- 
milk if  tolerated,  etc. 

Do  not  give  useless  drugs.  Treat  symptoms,  such  as  h^-perpyrexia, 
constipation,  suppression  of  urine,  and  assist  the  emunctories.  The  greatest 
part  of  the  treatment  is  the  management  of  convalescence — codliver-oil,  iron. 
Fellows'  compound  sjTup  of  hypophosphites,  malt  preparations,  cereals, 
butter,  eggs,  and  cream ;  meat  sparingly ;  all  green  vegetables ;  oranges  and 
lemons. 

Health  can  be  restored  by  cautious  management  during  the  stage  'of 
convalescence.  When  cough  remains  and  symptoms  point  to  the  beginning 
of  tuberculosis,  we  must  not  lose  sight  of  the  fact  that  more  can  be  accom- 
plished by  climatic  treatment — out  of  doors,  in  the  country — than  by  in- 
door treatment.  Complete  change  of  air,  to  a  more  even  climate  like 
Denver,  Colo.,  New  Mexico,  or  Florida,  will  frequently  restore  the  lungs  to 
their  normal  condition. 


CHAPTEK  IX. 
SCARLET  FEVER  (SCARLATINA). 

Scarlet  fever  is  an  acute  infectious,  specific  and  contagious  disease. 
This  disease  is  usually  ushered  in  by  vomiting  and  sore  throat,  accompanied 
by  fever.    If  the  child  is  old  enough  it  will  complain  of  headaches. 

The  pulse-rate  will  be  accelerated,  and  there  is  usually  on  the  second 
day  a  distinct  eruption  visible.  This  disease  presents  several  types:  the 
mildest  form,  known  as  scarlatina  simplex  or  the  benign  form,  and  the 
most  malignant  type,  scarlatina  maligna,  called  by  the  French  "fou- 
droyante." 

There  are  a  great  many  varieties  between  the  two  types  just  men- 
tioned, so  that  any  sharp  differentiation  is  quite  impossible. 

Of  the  many  varieties,  those  most  frequently  met  with  are:  First, 
mild ;  second,  septic,  and  occasionally  the  hsemorrhagic  type  is  seen. 

Etiology. — It  has  been  established  beyond  doubt  that  disease  germs 
even  though  they  might  exist  in  desquamated  cuticle  die  when  exposed  to 
the  air.  The  theory  of  the  transmission  of  scarlet  fever  by  such  means  is 
wrong.  That  the  disease  is  transmitted  through  the  air  has  not  been  estab- 
lished.   Personal  contact  is  necessary. 

Infection  by  Contact. — In  Paris,  the'  Pasteur  Hospital  has  demon- 
strated that  infection  in  hospitals  can  be  minimized  by  avoiding  contact. 
Grancher,  in  Paris,  employed  wire  screens  around  the  beds  to  impress  the 
nurses  of  the  necessity  for  guarding  against  infection  by  contact. 

Scarlet  Fever  and  Milk. — Hall,^  in  a  very  interesting  article,  found, 
after  an  extensive  review  of  the  literature,  that,  "while  scarlet  fever  occurs 
in  epidemic  form  in  those  countries  where  cows'  milk  forms  a  staple  article 
of  food,  especially  among  children,  it  does  not  occur  in  countries  where 
cows'  milk  is  not  used  as  a  food,  or  where  children  are  raised  on  mother's 
milk  only."  This  is  true  of  Japan,  where  cows'  milk  is  not  used  and 
domestic  animals  are  scarce,  and  it  is  true  in  India,  also,  where,  though 
cows'  milk  is  used,  the  children  are  nursed  by  their  mothers  until  they  are 
3  or  4  or  even  6  years  of  age. 

While  this  immunity  from  scarlet  fever,  together  with  the  absence 
of  cows'  milk  as  an  article  of  food,  may  be  simply  a  coincidence  otherwise 
explainable,  does  it  not  suggest  the  possibility  of  infection  through  the 
gastro-intestinal  tract  as  perhaps  the  chief  source? 

Climate. — Epidemics  are  more  common  in  America  in  the  fall  and 
winter  than  in  the  summer  months,  although  I  have  seen  malignant  cases 


^H.  0.  Hall:     New  York  Medical  Record,  November  11,  1899,  p.  698. 

(599) 


600 


THE  INFECTIOUS  DISEASES. 


both  in  hospital  and  private  practice  just  as  bad  in  midsummer  as  in  mid- 
winter. We  know  by  clinical  experience  that  the  poison  of  scarlet  fever  is 
less  volatile  than  that  of  measles,  and  is  not  transmitted  any  great  distance 
through  the  atmosphere  (Hall) . 

Table  No.  61. — Scarlet  Fever  Gases  Occurring  in  Children  Under  18  Years. 
Willard  Parker  Hospital. 


oa 

^ 

tM 

03 

03 

as 

ID 

cs 

03 

03 

^ 

<I> 

TS 

n 

M 

>^ 

>H 

t» 

>H 

H 

>* 

o 

(N 

iC 

00 

a 

•a 

O 

o 

O 

o 

o 

o 

o 

o 

O 

o 

o 

d3 

P 

iH 

+3 

CO 

TP 

lO 

«5 

t> 

CO 

o 

(N 

lO 

Male 

870 

7 

39 

80 

105 

76 

90 

87 

87 

113 

65 

69 

62 

1910 

Female 

914 

11 

40 

82 

93 

81 

109 

92 

80 

126 

84 

78 

38 

Total 

1784 

18 

79 

162 

198 

157 

199 

179 

167 

239 

149 

147 

90 

Male 

705 

9 

28 

60 

65 

72 

84 

90 

45 

69 

104 

38 

41 

1911 

Female 

947 

9 

58 

75 

100 

90 

110 

99 

90 

160 

37 

69 

60 

Total 

1652 

18 

86 

135 

165 

162 

194 

189 

135 

229 

141 

97 

101 

Age. — The  greater  number  of  cases  occur  between  the  ages  of  5  and  10 ; 
next  in  frequency,  2  to  5,    Then  the  frequency  gradually  diminishes. 

Stage  of  Incubation. — Authorities  differ  as  to  the  length  of  time  that 
usually  elapses  between  the  exposure  to  the  disease  and  the  appearance 
of  symptoms.  The  usual  rule"  is  from  a  few  days  to  a  week,  although 
exceptions  will  extend  the  time  to  several  days  longer. 

Eichhorst  and  von  Leube  give  it  from  four  to  seven  days.  Individual 
susceptibility  plays  an  important  part  in  scarlet  fever  as  well,  as  we  have 
seen  in  other  diseases. 

Henoch  maintains  that  we  cannot  form  an  idea  of  the  severity  or 
mildness  of  an  attack  by  the  early  symptoms. 

Table  No.  62. — Statistics  of  Cases,  of  Scarlet  Fever  Treated  in  the 
Riverside  Hospital,  New  York  City. 


Ye  r. 

Number  of 
Cases. 

Deaths. 

Mortality 
Per  cent. 

190:3  .... 

1904,  Jan.  to  Oct. 

835 
718 

76 
46 

9.1 
6.4 

Bacteriology. — ^The  distinct  specific  cause  of  scarlet  fever  is  unknown, 
in  spite  of  immense  scientific  work.  A  specific  micro-organism  first  de- 
scribed by  Class^  is  a  non-capsulated  diplococcus,  appearing  occasionally  in 

^New  York  Medical  Record,  September,  1899,  p.  330. 


SCARLET  FEVER. 

a 


601 


Fig.  192.— a,  "Inclusion  Bodies,"  case  of  Scarlet  Fever.  A,  Neutro- 
phile  granules.  6,  "Inclusion  Bodies,"  case  of  Scarlet  Fever  following  ex- 
tensive burns  of  the  body.     {Kolmer.y 


602  THE  INFECTIOUS  DISEASES. 

Tabie  No.  63. — Scarlet  Fever  Cases  Treated  at  Willard  Parker  Hospital. 

1910  1911  1912 

Number  of  cases  treated  2302  1984  2127 

Total  number  of  deaths 247  211  179 

Percentage   mortality    10.7  10.6  08.41 

Total  number  dying  within  24  hours    .^.  .  . .        19 

Percentage    mortality    0.8 

Total  number  dying  within  48  hours   36  38  27 

Percentage   mortality 01.5  01.9  01.2 

streptococcic  form,  pol5anorphous  in  character.  It  is  constantly  found  in 
the  pharynx  in  scarlatinal  angina. 

Baginsky  and  Sommerfeld^  found  a  streptodiplococcus  in  the  pharynx 
and  blood  in  scarlet  fever  which  they  believe  to  be  the  etiological  factor  in 
that  disease.  As  yet  scarlet  fever  cannot  be  reproduced  in  animals,  and 
hence  this  microbe  must  be  looked  upon  as  the  probable  causative  factor. 
Owing  to  the  immense  amount  of  research  work  being  done,  the  day  is  not 
far  distant  when  the  specific  factor  of  all  infectious  diseases  will  be 
discovered. 

Pathology. — The  gross  and  histological  lesions  found  post-mortem  in 
scarlet  fever  depend  essentially  upon  two  processes:  first,  the  action  of  the 
scarlatinal  toxin,  associated  with  the  changes  seen  in  any  acute  febrile  dis- 
ease ;  and,  secondly,  they  may  occur  as  a  result  of  a  mixed  infection  due  to 
entrance  into  the  organism  of  the  streptococcus  pyogenes,  the  staph54ococcus 
pyogenes  aureus  or  albus,  the  pneumococcus,  and,  rarely,  other  micro-organ- 
isms. So  long  as  the  specific  agent  concerned  in  the  scarlatinal  infection 
remains  obscure,  it  must  be  impossible — in  many  instances  at  least — 
to  determine,  in  a  given  case,  which  of  these  two  elements  is  the  predomi- 
nant one.  In  cases  succumbing  early  in  their  course  to  the  intensity  of  the 
poison,  before  the  development  of  secondary  infections,  we  must  assume 
the  changes  present  to  be  due  to  the  specific  scarlatinal  virus,  while  in  those 
which  prove  fatal  later,  associated  with  grave  throat  lesions,  streptococcic 
angina,  etc.,  the  possibility  of  an  added  etiological  element  in  the  lesions 
present  after  death  must  be  admitted  ( Corlett) . 

The  Blood. — The  diagnostic  importance  of  inclusion  bodies  in  scarlet 
fever  has  been  confirmed  by  many  observers,  A  true  scarlet  fever  can  fre- 
quently be  determined  by  the  presence  or  absence  of  the  inclusion  bodies. 
Thus,  the  absence  of  the  inclusion  bodies  means  serum  exanthem  and  not 
scarlet  fever. 

Inclusion  Bodies. — Inclusion  bodies  were  described  by  Dohle  in  1911. 
These  bodies  are  found  within  the  cytoplasm  of  the  polymorphonuclear 
leucocytes.  Since  then  Kretschmer,  in  Berlin,  and  Nicholl  and  Williams, 
in  New  York,  have  not  only  confirmed  these  findings,  but  lay  stress  on 


^Berlin,  klin.  Woch.,  No.  22,  1900,  p.  588. 


SCARLET  FEVER.  603 

the  diagnostic  value  of  these  bodies  in  scarlet  fever.  These  bodies  occur 
early  in  the  disease,  usually  during  the  first  five  days  of  the  infection.  A 
simple  blood  smear  on  a  clean  slide  and  stained  by  Giemsa  or  Wright  and 
Jenner  method  will  bring  them  out.  Kolmer  reports  30  cases  of  serum 
sickness  showing  urticarial  rashes  ten  days  after  admission  to  the  Philadel- 
phia Hospital;  not  one  showed  the  presence  of  inclusion  bodies.  Twelve 
cases  of  measles  were  examined  and  all  were  negative;  1  case  of  rotheln, 
negative.  Of  eleven  cases  of  erysipelas  examined  inclusion  bodies  were  pres- 
ent in  7.  Inclusion  bodies  seem  to  be  present  not  only  in  scarlet  fever,  but 
also  in  other  streptococcus  infections.  In  diphtheria  inclusion  bodies  are 
frequently  noted.  As  a  rule,  in  the  early  stages  of  a  rash  following  an  in- 
jection of  antitoxin  the  absence  of  the  inclusion  bodies  speaks  in  favor  of 
serum  exanthem  and  against  scarlet  fever. 

Bowie^  reports  167  cases  with  a  total  number  of  714  counts. 
Of  these,  77  were  differential  to  determine  the  relative  percentage  of  the 
three  main  varieties  of  leucoc5i^es.  The  following  is  the  summary  of  his 
conclusions : — 

1.  Practically  all  cases  of  scarlet  fever  show  leucocytosis. 

2.  The  leucocytosis  begins  in  the  incubation  period,  very  shortly  after 
infection ;  reaches  its  maximum  at  or  shortly  after  the  height  or  severity  of 
the  disease,  and  then  gradually  sinks  to  normal. 

3.  In  simple,  uncomplicated  cases  the  maximum  is  reached  during  the 
first  week,  and  the  normal  generally  some  time  during  the  first  three  weeks. 

4.  The  more  severe  the  case  the  higher  is  the  leucocytosis,  and  the 
longer  it  lasts;  the  milder  the  case  the  slighter  the  leucocytosis,  and  the 
shorter  time  it  lasts. 

5.  A  favorable  case  of  any  variety  of  the  disease  has  always  a  higher 
leucocytosis  than  an  unfavorable  one  of  the  same  variety. 

6.  The  temperature  has  no  effect  on  the  leucocytosis. 

7.  The  polymorphonuclear  leucocytes  are  increased  relatively  and  abso- 
lutely at  first,  and  then  fall  to  the  normal,  the  lymphocytes  acting  inversely 
to  this.     This  cycle  of  events  occurs  in  simple  cases  within  three  weeks. 

8.  Eosinophiles  are  diminished  at  the  onset  of  the  fever.  They  in- 
crease rapidly  in  simple  favorable  cases  till  the  height  of  the  disease  is  past, 
then  diminish,  and  finally  reach  the  normal  some  time  after  the  sum  total 
leucocytosis  has  disappeared — in  short,  when  the  poison  has  all  been  elimi- 
nated. 

9.  The  more  severe  the  case  the  longer  are  the  eosinophiles  subnormal 
before  they  rise  again.  In  fatal  cases  they  never  rise,  but  sink  rapidly 
toward  zero. 


1  Reported  in  Berlin,  klin.  Wochenschrift.     (No.  31,  1897.) 


604  THE  INFECTIOUS  DISEASES. 

10.  The  leucocytes,  in  complications,  go  through  a  cycle  of  events 
similar  in  all  respects  to  that  of  the  primary  fever  as  regards  both  sum 
total  and  differential  leucocytosis,  and  the  same  laws  govern  the  behavior  of 
the  leucocytes  in  both  cases. 

In  regard  to  the  diagnosis  of  scarlet  fever,  the  simple  counting  of  the 
leucocytes  gives  little  aid.  A  differential  count,  however,  may  be  of  aid, 
for  scarlet  fever  is  one  of  the  few  acute  infectious  diseases  where  one  finds 
an  increase  in  the  eosinophiles  early  in  the  disease  and  the  persistence  of 
that  increase  for  some  time. 

With  regard  to  prognosis,  the  examination  of  the  leucocytes  seems 
likely  to  be  of  some  practical  value.  In  scarlatina  simplex,  if  the  case  be 
severe,  and  the  leucocytosis  be  high  and  rising,  one  may  predict  a  favorable 
course ;  and  conversely,  if  it  be  low  and  stationary,  one  may  expect  a  tedious 
case.  Eegarding  the  differential  count,  if  the  eosinophiles  show  a  relative 
increase,  the  augury  is  good ;  if  they  are  normal  or  siibnormal  after  the  first 
day  or  two,  then  the  case  will  in  all  probability  be  a  severe  one.  Further- 
more, as  long  as  a  relative  increase  of  eosinophiles  is  present  one  cannot  be 
sure  that  some  complication  will  not  ensue;  whereas,  if  the  eosinophiles 
have  come  down  to  normal  in  the  usual  way,  one  may  be  free  from  anxiety 
in  this  respect. 

Symptoms. — The  onset  is  usually  very  sudden.  In  young  children  the 
attack  is  preceded  by  a  convulsion.    Vomiting  is  an  early  symptom. 

Tongue. — The  tongue  has  a  whitish  fur  and  the  papillae  will  be  found 
elevated  and  very  red.  It  has  the  so-called  "strawberry"  appearance  (see 
Plate  XXYIII).  The  throat,  especially  the  tonsils,  will  be  found  intensely 
congested  and  dry.  Sometimes  a  severe  diarrhoea  is  the  first  symptom. 
The  pulse  is  full  and  rapid,  from  120  to  140  beats  per  minute.  The  tem- 
perature on  the  first  or  second  day  is  about  102°  F.,  rarely  higher. 

Glands. — Enlarged  inguinal  glands  are  a  characteristic  feature  of  this 
disease.  The  submaxillary  lymphatic  glands  at  the  angle  of  the  jaw  are 
swollen  and  tender  on  palpation.  The  mucous  membrane  of  the  mouth  is 
reddened.  The  pharynx,  tonsils,  and  the  uvula  are  injected.  Monti^  calls 
attention  to  an  enanthem  in  scarlet  fever  which  is  seen  late  on  the  first  day 
or  early  on  the  second.  It  is  a  diffused,  mottled  reddening,  which  begins 
upon  the  uvula,  spreads  quickly  over  the  hard  and  soft  palate,  covering  the 
pillars  of  the  fauces,  and  finally  the  mucous  membrane  of  the  cheeks. 

The  Urine. — ^There  is  febrile  albuminuria  present,  which  disappears 
as  the  temperature  declines.    The  urine  is  scanty  and  high-colored. 

The  Hash. — This  appears  usually  within  the  first  twenty-four  hours. 
It  is  first  seen  upon  the  neck  and  chest — less  often  upon  the  small  of  the 
back.  It  is  a  bright-scarlet  pin-point  flush,  and  occupies  the  sites  of  the 
hair  follicles.     The  rash  extends  from  above  downward,  spreading  in  a 

^vT^hrb.  f.  Kindh.,  vol.  vii,  p.  227. 


j'l.ATK  xxvrn 


strawberry  Tongiie  in  Scarlet  Fever.     Painted  from  a  case  in  the  Riverside 
Hospital.     The  body  rash  is  shown  in  the  Frontispiece.      (Original.) 


Beefy  Tongue  in  Scarlet  Fever.  The  tongue  has  a  glazed  appearance. 
The  papillae  are  enlarged.  This  type  is  usually  seen  when  desquamation 
begins,  after  the  rash  has  faded.  Painted  at  the  bedside  from  a  case  in  the 
Riverside  Hospital.     (Original.) 


SCARLET  FEVER. 


eoi 


few  hours  to  the  arms;  usually  in  twenty-four  hours  it  reaches  the  trunk, 
legs,  and  abdomen.  (Study  frontispiece.)  A  point  to  note  is  that  in  con- 
trast to  measles  and  smallpox  it  is  much  less  marked  upon  the  face  and 
cheeks.  The  immediate  neighborhood  of  the  nose  and  mouth  remains  free 
from  the  eruption;  and  has  a  peculiar  pallor,  a  marked  contrast  to  the 
parts  affected  by  the  eruption.  The  dorsal  surfaces  of  the  hands  and  feet 
show  the  eruption.  The  palmar  and  plantar  surfaces,  though  frequently 
injected,  do  not  usually  show  the  true  punctate  scarlatina  rash. 

The  rash  shows  great  variations.     While  it  may  show  large  or  small, 
faintly  scarlet  colored  patches  lasting  but  a  short  time,  the  opposite  more 


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_ 

Fig.  193. — Septic  Scarlet  Fever  with  Myocarditis,  Suppurative 
Arthritis,  Double  Purulent  Otitis,  General  Pyaemia.  Case  seen  in  consulta- 
tion in  private  practice.     Child  4  years  old.     (Original.) 


frequently  occurs.  When  it  is  diffuse  it  may  be  of  an.  intense  scarlet  or 
almost  purple  color.  (See  frontispiece.)  It  frequently  shows  a  tendency 
to  stain  the  tissues,  and  minute  haemorrhages  may  occur  with  the  formation 
of  petechias. 

Septic  Scarlet  Fever. — ^This  type  is  most  commonly  met  with  in  chil- 
dren. The  symptoms  are  of  a  more  severe  type.  There  is  high  and  con- 
tinued fever,  with  involvement  of  the  pharynx  and  tonsils.  Prostration  is 
the  vital  symptom,  showing  the  evidence  of  severe  infection.  There  are 
marked  cerebral  symptoms,  such  as  extreme  restlessness,  convulsions,  or  mild 
delirium.  In  this  type  we  usually  have  persistent  vomiting  associated  with 
general  apathy.  The  fever  rises  suddenly  to  105°  F.,  or  40.5°  C,  or  higher. 
The  pulse  becomes  very  small  and  rapid,  from  140  to  160  per  minute,  al- 
though at  times  200  per  minute.  The  tliirst  is  extreme,  the  tongue  is  dry 
and  gums  parched.     The  tliroat,  especially  the  tonsil,  is  deeply  injected 


606  THE  INFECTIOUS  DISEASES. 

and  frequently  has  scattered  foci  of  exudate  on  the  surfaces.  The  urine  is 
concentrated,  and  invariably  contains  albumin. 

Hsemorrhag^c. — This  is  the  most  malignant  form  and  is  very  rare. 
The  disease  is  very  abrupt  in  its  onset.  The  temperature  reaches  105°  to 
107°  F.,  and  sometimes  higher,  within  the  first  few  hours. 

The  pulse  is  greatly  accelerated  and  is  weak  and  intermittent,  The 
cheeks  and  lips  are  blanched  and  may  show  cyanosis  very  early.  The  urine 
is  scanty,  high-colored,  and  albuminous,  or  may  be  completely  suppressed. 
There  are  marked  cerebral  disturbances,  such  as  convulsions  and  active 
delirium.  Frequently  we  have  marked  dyspnoea,  the  respiratory  rhythm 
being  short  and  quick,  due  usually  not  to  any  change  in  the  lungs  at  this 
time,  but  probably  to  irritation  of  the  respiratory  centers,  according  to 
Ausset.  Ataxic  and  adynamic  forms  are  characterized  by  early  and  pro- 
found constitutional  depression,  due  to  the  effect  of  the  toxin  on  the  nerve 
centers,  the  symptoms  rapidly  assuming  a  typhoidal  type. 

In  the  hsemorrhagic  forms  the  exanthem  acquires  a  dark-purplish  hue. 
Small  petechia,  varying  in  size  from  a  pin-head  to  a  lentil,  appear  scat- 
tered irregularly  over  the  body.  The  blood  oozes  from  the  gums,  the  sputum 
even  being  tinged  with  it,  while  epistaxis  may  be  severe.  Blood  may  be 
discharged  from  the  bowels  or  the  stools  may  be  tarry  in  color. 

Bleeding  is  frequently  seen  from  the  genito-urinary  tract  or  the  urine 
shows  the  presence  of  blood.  This  form  of  disease  is  usually  encountered  in 
very  feeble  infants  under  2  years  of  age  and  is  invariably  fatal. 

Scarlatina  Sine  Exanthemata. — Cases  frequently  occur  in  which  every 
evidence  of  scarlet  fever  exists,  but  there  is  no  eruption.  Henoch  states 
that  he  believes  the  eruption  is  always  present  and  thinks  that  it  is  occa- 
sionally overlooked.  The  eruption  is  frequently  of  such  an  evanescent  char- 
acter that  it  entirely  escapes  notice,  but  a  subsequent  desquamation  and 
nephritis  will  usually  strengthen  the  diagnosis. 

A  case  of  scarlatina  sine  exanthemata  was  seen  by  me  in  the  family  of  Dr.  J. 
Lurie„  of  New  York  City.  A  child  about  4  yea/rs  old  had  been  in  apparent  health. 
There  was  no  history  of  vomiting  nor  any  gastric  disturbances.  No  history  of  ex- 
posure to  scarlet  fever.  When  examined  by  me  I  found  no  evidences  of  scarlet 
fever.  The  throat  was  somewhat  congested,  but  had  no  patches,  nor  was  there  any 
evidences  of  necrotic  membrane  visible  in  any  portion  of  the  throat.  The  lymphatic 
glands  of  the  neck  were  not  enlarged.  The  urine  was  very  scanty  and  contained 
more  than  50  per  cent,  by  volume  of  albumin.  Blood  was  also  present  in  large 
quantity.  There  were  also  hyaline,  epithelial,  and  granular  casts  present  when  a 
drop  was  examined  under  the  microscope. 

The  child's  urine  was  greatly  diminished  in  quantity,  hardly  a  tablespoonful 
being  passed  at  one  sitting.  Diuretin  and  citrate  of  potash  acted  very  well  as 
diuretics,  and  later  the  secretion  of  urine  was  normal  in  both  quality  and  quantity. 
At  times  it  seemed  as  though  the  urine  consisted  of  pure  blood.  Later  the  child 
developed  an  otitis  media,  which  was  preceded  by  a  rise  in  temperature.  The  child 
made  a  good  convalescence  and  is  perfectly  well  to-day. 


PLATE  XXIX 


Scarlet   Fever,   Willard   Parker   Hospital. 

1.  Fiirfuraceous    Desquamation.      2.  Circinate    Desquamation. 
3.  Flaky   Desquamation. 

(Courtesy  of  Dr.  Howard  Fox.) 


SCARLET  FEVER. 


607 


Scarlatina  Papulosa. — Small,  slightly  elevated  papules  of  a  dark-red 
color  develop  at  the  site  of  the  hair  follicles.  They  are  more  readily  de- 
tected by  the  finger  than  by  the  eye,  and  are  observed  twelve  to  eighteen 
hours  before  the  ordinary  scarlatinal  rash  appears. 

Scarlatina  Variegata. — ^This  form  is  marked  by  an  extremely  irregular 
distribution  of  the  eruption,  frequently  associated  with  the  development  of 
well-defined  macular  areas  of  an  intense  red  color,  situated  at  the  site  of  the 
hair  follicles,  and  in  many  instances  simulating  the  exanthem  of  measles. 

Scarlatina  Sine  Febre. — Among  extremely  mild  cases  of  scarlatina  in- 
stances are  frequently  seen  in  which,  after  a  slight  initial  rise,  the  disease 


Fig.    194. — Unusually  Severe  Desquamation. 

(Original.) 


Willard  Parker  Hospital. 


progresses  without  any  subsequent  elevation  of  temperature  above  98.5°  to 
99°  F.,  every  other  symptom  being  present,  but  in  a  mild  degree. 

Henoch  reports  4  cases  out  of  175  with  irregularities  of  temperature. 
Feve?  of  an  inverted  type  has  been  reported  by  Henoch,  who  noted  the  tem- 
perature curve  quite  the  reverse  of  normal,  in  which  the  temperature  was 
higher  in  the  morning  than  in  the  evening. 

Scarlatina  Sine  Angina. — This  form  of  scarlatina  has  very  slight  throat 
symptoms  or  so  insignificant  as  to  appear  almost  absent.  A  slight  conges- 
tion of  the  throat  is  visible,  and  usually  a  faint  enanthem  is  present  early 
in  the  disease. 

The  tonsils  are  not  enlarged,  but  tliere  is  an  almost  constant  enlarge- 
ment of  the  papillce  at  the  tip  and  edges  of  the  tongue — an  important  diag- 
nostic aid. 

Desquamation. — The  desquamation  of  the  skin  in  scarlatina  begins 
over  those  areas  on  which  the  rash  was  first  seen,  namely,  the  thorax  and 


608  THE  INFECTIOUS  DISEASES. 

neck.  Thus,  we  will  frequently  find  evidences  of  desquamation  on  one  part, 
while  another  part  of  the  body  has  distinct  traces  of  the  rash. 

Character  of  the  Desquamation. — On  the  neck,  face,  and  trunk  the 
epidermis  peels  ofE  in  fine,  flaky  scales.  This  is  known  as  desqimmatio 
furfuracea.  This  is  similar  to  the  desquamation  found  in  measles.  The 
extremities,  about  the  hands  and  feet,  show  the  characteristic  desquamation. 
The  epidermis  peels  off  or  can  be  stripped  off  in  shreds  of  varying  lengths. 
This  is  known  as  desquamatio  memtmnacea  or  lamellosa. 

Duration  of  Desquamation. — ^This  varies  greatly  and  is  influenced  by 
the  severity  of  the  infection  and  the  intensity  of  the  eruption.  It  persists 
longest  where  the  epidermis  is  thick,  namely,  about  the  hands  and  feet.  At 
times  it  will  be  necessary  to  soak  the  hands  and  feet,  then  mb  them  with 
pumice  stone  to  hasten  the  removal  of  the  epidermis. 

The  length  of  time  for  complete  desquamation  may  be  from  sis  to 
eight  weeks.  It  may  be  of  a  shorter  or  longer  ■  duration.  Eepeated  des- 
quamation is  not  uncommon,  so  that  we  can  say  there  is  secondary  and,  less 
frequently,  tertiary  desquamation. 

Complications. — Scarlatina  with  Other  Exanthemata:  Mixed  infec- 
tions are  frequently  noted.  Measles,  chicken-pox,  or  smallpox  are  met  with. 
Corlett  depicts  a  case  of  scarlatina  with  chicken-pox. 

Mixed  infections  have  been  seen  many  times  during  my  service  in  the 
scarlet  fever  wards  of  the  Eiverside  Hospital — scarlet  fever  and  whooping- 
cough,  scarlet  fever  and  measles  very  often,  scarlet  fever  and  diphtheria  as 
well. 

The  Throat. — Scarlatina  is  usually  seen  very  early  in  the  pharynx  and 
fauces.  This  takes  place  whether  we  are  dealing  with  a  mild  or  severe  in- 
fection. We  know  that  certain  pathogenic  bacteria,  such  as  streptococci,  are 
invariably  found  during  the  course  of  scarlatina.^ 

Many  bacteriologists  agree  that  the  Klebs-Loeffler  .bacillus  is  usually 
absent,  though  there  are  many  cases  of  true  diphtheria  complicating  scarlet 
fever.  Several  cases  of  diphtheritic  angina  have  been  seen  by  me  while  on 
service  at  the  scarlet  fever  wards  of  the  Riverside  Hospital.  Lemoine  found 
the  streptococcus  pyogenes  in  93  cases  out  of  117  studied  by  him.  The 
Klebs-LoefQer  bacillus  was  found  in  addition  in  5  cases  of  this  series,  and 
the  bacillus  coli  communis  in  9  cases. 

Angina  Pseudomemhranosa  {of  Streptococcic  Origin). — False  mem- 
branes upon  the  tonsils  or  pharjTix  are  seen  in  the  severe  and  septic  tj^es 
of  this  disease.  It  is  simply  a  necrotic  inflammatory  deposit.  On  the  second 
day  the  mucous  membrane  of  the  phar}-nx  is  intensely  reddened  and  con- 
gested.   The  tonsils,  which  are  much  inflamed  and  swollen,  show  scattered. 

^  See  elaborate  clinical  and  bacteriological  studies  made  by  Baginsky  and 
Sommerfeld,  in  Archiv  fiir  Kinderheilkunde,  1900,  and  Berlin,  klin.  Woch.,  No.  22, 

1900,  p.  588. 


SCARLET  FEVER. 


609 


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39 


6i6  THE  INFECTIOUS  DISEASES. 

irregular  patches  of  gray  or  grayish-white  exudate,  completely  occluding  the 
tonsillar  crypts  over  a  more  or  less  limited  surface.  One  or  both  tonsils 
may  be  affected.  In  many  instances  the  pharyngeal  inflammation  from  the 
beginning  shows  an  extreme  grade  of  intensity.  This  may  spread  over  the 
posterior  pharyngeal  wall,  the  hard  palate,  and  the  mucous  membrane  of 
the  posterior  surface  of  the  cheek;  also,  to  the  posterior  nares  and  the 
Eustachian  tube,  with  resulting  extension  of  the  inflammatory  process  to 
the  middle  ear.  There  is  a  very  foul  odor  to  the  breath,  and  usually  a  thin, 
acrid  secretion  from  the  nostrils,  causing  excoriation,  fissures,  and,  rarely, 
rhagades. 

The  nostrils  may  be  occluded  and'  the  mouth  held  open  in  an  attempt 
to  breathe. 

Angina  Scarlatina  Membranosa  {of  True  Diphtheritic  Origin). — ^This 
should  be  regarded  as  a  true  diphtheritic  complication  and  treated  as  diph- 
theria (see  chapter  on  "Diphtheria''), 

Otitis. — The  extension  of  the  infection  from  the  pharynx  through  the 
Eustachian  tubes  has  already  been  mentioned.  As  a  rule,  the  younger  the 
child,  the  greater  the  danger  of  otitis.  According  to  Bader  and  Guinon,  the 
mild  or  catarrhal  form  occurs  in  33  per  cent,  of  all  cases  of  scarlet  fever, 
and  the  purulent  form  is  less  common,  occurring  in  4.5  per  cent,  of  all 
eases. 

Caiger,  reporting  4015  cases  of  scarlet  fever,  noted  ear  discharge  in 
11.05  per  cent.  In  a  series  of  397  cases  observed  by  me,  including  severe, 
malignant,  and  all  complicated  varieties,  there  were  82  middle-ear  dis- 
charges, 68  purulent  and  14  catarrhal. 

About  20  per  cent,  of  all  cases  seen  by  me  had  middle-ear  trouble.  It 
is  important  to  have  the  middle  ear  examined  when  high  fever  persists 
during  an  attack  of  scarlet  fever.  Persistent  high  fever  in  a  case  of  scarlet 
fever  occurred  in  my  private  practice.  It  was  also  seen  by  Dr.  J.  W. 
Brannan  and  by  Dr.  Dench.  After  an  examination  of  the  middle  ear,  a 
thorough  incision  of  the  drum  membrane  liberated  pus  and  relieved  the 
temperature  for  a  time. 

The  hand  will  frequently  be  carried  to  the  head  or  ear.  The  neigh- 
boring lymphatic  glands  are  enlarged,  palpable,  and  may  be  tender.  After 
a  few  days,  unless  relieved  by  incision,  the  tympanic  membrane  ruptures 
spontaneously.  The  symptoms  then  usually  subside.  When,  however,  the 
inflammation  becomes  purulent  (otitis  media  suppurativa),  then  the  con- 
dition is  serious,  owing  to  the  possibility  of  deafness  arising. 

Empyema  of  the  mastoid  antrum,'^  resulting  from  chronic  suppurative 
otitis  media,  occurs  in  a  small  percentage  of  cases.  With  the  establishment 
of  a  communication  between  the  tympanic  cavity  and  the  cells  of  the  mas- 
toid, there  is  usually  a  slight  decrease  in  the  amount  of  discharge  from  the 


^Read  article  on  mastoid  (chapter  on  "Otitis"),  page  815. 


SCARLET  FEVER.  611 

Table  No.  64. — Complications  in  Scarlet  Fever.     Willard  Parker  Hospital. 

Year    1910  1911  1912 

Number  of  cases   2302  1984  2127 

Eyk  Complications. 

Conjunctivitis    (purulent)     86  68  1 

Conjunctivitis    (gonorrhoeal)     14  13  3 

Conjunctivitis    (catarrhal)    28  142  84 

Ear  Complications. 

Mastoiditis    (operative)     14  25 

Mastoiditis     (non-operative)     8  37  25 

Otorrhoea   ( purulent)    180  194  249 

Otorrhoea    (diphtheritic)    5  14 

Throat  Complications. 

Positive  throat  cultures  on  admission   358  33  117 

Requiring    intubation     11  7  74 

Intubation  cases  recovered    8 

Tonsillitis    89  74 

Regurgitation    27  22 

Adenitis    (cervical)     512  274  120 

Cardiac  Complications. 

Endocarditis    32  61  49 

Myocarditis    29  41  56 

Pericarditis    (with  effusion)     2  5  1 

Pericarditis   (fibrinous)    3  4  3 

Bradycardia    25  16 

Irregularity    125  369 

Nephritic  Complications. 

Albuminuria    391  357  281 

Nephritis    (marked)    53  34  51 

Uremic  convulsions  11  9  8 

General  Complications. 

Arthritis    85  145  148 

Delirium    17  95  72 

Erysipelas    11  1  11 

Pneumonia    34  160  114 

Empyema    4  3  4 

Measles     86  94 

Typhoid  on  admission  4  3  1 

Antitoxin  rashes 

Morbilliform    10  21 

Scarlatiniform    38  15 

Urticarial 30  45 

Erythema  multiforme   47  27 


612  THE  INFECTIOUS  DISEASES. 

ear.  The  temperature  rises  to  104°  F.,  or  higher,  and  shows  a  marked 
fluctuation  of  a  remittent  character.  There  may  he  rigors.  If  old  enough 
the  child  will  complain  of  pain  in  the  mastoid  region  with  tenderness  on 
palpation  over  the  mastoid  process. 

The  pulse  becomes  rapid  and  irregular.  These  symptoms  continue  from 
day  to  day,  and  unless  an  operation  is  performed  these  cases  will  end  fatally, 
due  to  the  development  of  meningitis. 

More  rarely  an  inflammatory  swelling  appears  behind  the  external 
ear — situated  over  the  mastoid — associated  with  a  rise  of  temperature,  local 
tenderness,  with  more  or  less  forward  projection  of  the  ear,  and  occasionally 
local  suppuration,  with  abscess  formation,  takes  place. 

Mastoid  Infections. — The  virulence  of  the  streptococcus  and  the  pneu- 
mococcus  must  always  be  remembered.  In  addition  to  the  streptococcus, 
some  cases  will  show  the  presence  of  the  staphylococcus.  In  one  of  my  cases 
seen  recently,  we  encountered  an  almost  pure  culture  of  bacillus  pyocyaneus. 
This  latter  condition  is  extremely  rare. 

These  bacteria  always  accompany  both  the  severe  and  mild  forms  of 
infection  and  predominate  in  the  nose  and  throat.  The  proximity  of  the 
Eustachian  tube  permits  these  bacteria  to  penetrate  into  the  deeper  struc- 
tures and  thus  reach  the  mastoid.  It  is  therefore  important  to  have  in  mind 
the  ease  with  which  a  middle-ear  disease  may  begin. 

When  fever  persists,  daily  inspection  of  the  ear  should  be  made.  If 
the  temperature  rises  and  the  child  shows  discomfort  and  pain,  and  there  is 
the  slightest  bulging  or  redness  of  the  tympanic  membrane,  no  time  should 
be  lost,  but  an  incision  made. 

Many  cases  of  otitis  will  yield  promptly  when  the  drum  is  incised  and 
pus  drainage  established.  When  tenderness  exists  over  the  mastoid,  an  ice- 
bag  or  a  cold-water  coil  will  afford  relief. 

After  the  incision  of  the  tympanic  membrane  warm  saline  irrigations, 
three  times  a  day,  are  indicated.  This  will  clean  away  all  the  discharge,  and 
prevent  the  incision  from  closing.  When  thick,  tenacious  discharge  is  pres- 
ent which  cannot  be  washed  away,  it  must  be  wiped  away  by  means  of  an 
applicator  mounted  with  dry  absorbent  cotton.  While  some  otologists  ad- 
vise plugging  the  ear  with  absorbent  cotton,  I  have  had  better  results  by 
allowing  free  drainage. 

A  case  of  this  kind  occurred  in  the  private  practice  of  Dr.  R.  W.  Reid,  of  New 
York  City,  with  whom  I  saw  the  case  in  consultation.  The  child  had  a  very  severe 
attack  of  scarlet  fever.  It  was  of  a  septic  character.  Necrotic  membranes  could  be 
seen  over  the  pharynx  and  tonsils.  There  was  persistent  fever.  The  child  was 
decidedly  rachitic.  The  case  was  complicated  with  an  acute  nephritis.  The  urine 
was  very  scant  and  was  loaded  with  albumin  and  casts.  Later  the  right  ear  dis- 
charged pus  very  freely. 

When  I  saw  the  child  there  was  a  superficial  swelling  over  the  mastoid  which 
pushed  the  ear  forward.     The  inflammatory  condition  was  local  and  due  either  to 


SCARLET    FEVER.  fil3 

periostitis  or  to  a  local  adenitis,  remotely  dependent  on  the  middle  ear  suppuration. 
An  incision  made  liberated  a  large  quantity  of  pus.  The  child  died  of  general  septi- 
csemia  following  toxic  nephritis. 

Angina  Ludovici  (Tippet  Neck). — This  may  occur  about  the  fifth  day 
of  the  disease,  though  more  connnonly  seen  early  in  the  second  week  of  the 
attack. 

The  skin  is  indurated,  glossy,  and  may  pit  on  pressure,  though  it  may 
give  no  sense  of  fluctuation.  The  process  may  be  limited  to  the  .angle  of 
the  jaw  or  involve  the  entire  neck;  it  may  extend  downward  to  the  clav- 
icles and  upward  along  the  sides  of  the  face  and  head,  rendering  the  head 
almost  if  not  wholly  rigid.  The  diffuse  cellulitis  of  the  deeper  tissues  con- 
stitutes one  of  the  gravest  complications  of  scarlet  fever,  proving  almost 
invariably  fatal.  Death  results  from  a  rupture  of  one  of  the  large  vessels, 
the  jugular  vein  or  internal  carotid  artery,  or,  as  a  result  of  thrombosis 
or  embolism,  with  fatal  meningitis  or  pyaemia.  The  greater  the  toxaemia, 
the  more  pronounced  the  lymphatic  enlargement. 

The  Lymph  Glands. — The  neighboring  glands  are  enlarged  and  tender 
on  palpation.  The  infiltration  of  the  glands  may  be  extreme,  and  in  rare 
instances  an  excessive  infiltration  of  the  cellular  tissue  of  the  neck  occurs, 
which  becomes  hard  and  indurated,  and  occasionally  renders  the  head  im- 
movable. 

Phlegmonous  Inflammation  of  the  Neck — Diffuse  Cellulitis.^ — Scham- 
berg  studied  the  glands  in  100  cases  of  scarlatina.  He  found  the  maxillary 
glands  enlarged  in  95  per  cent,  and  the  submaxillary  glands  enlarged  in  36 
per  cent,  of  his  cases.  The  posterior  cervical  glands  were  found  enlarged 
in  77  per  cent,  of  the  cases.  Sometimes  the  parotid  glands  are  also  in- 
volved. Frequently  the  inflammatory  condition  persists  and  suppuration 
occurs,  resulting  in  so-called  phlegmonous  inflammation.  Even  when  freely 
incised  there  is  danger  of  pus  burrowing  beneath  the  connective  tissue. 
Sometimes  a  rapid  and  diffuse  cellulitis  with  excessive  infiltration  of  the 
deeper  tissues  is  associated  with  the  suppurative  process. 

Retropharyngeal  abscess  occurs  occasionally.^  Bokai  found  6  cases  out 
of  664  cases  of  scarlet  fever. 

Schamberg,  in  a  study  of  the  lymphatic  glands  in  scarlatina,  found  the 
various  groups  enlarged  in  the  following  proportion  in  100  cases : — 

Inguinal  glands    100  per  cent. 

Axillary    96  per  cent. 

Maxillary    95  per  cent. 

Posterior  cervical 77  per  cent. 


'•Schamberg:  Annals  of  Gynsecol.  and  Pediatry,  December,  18S9,  vol.  viii,  p.  39. 
'  Jahrbuch  f.  Kinderheilkunde,  vol.  x,  p.  108. 


614  THE  INFECTIOUS  DISEASES. 

Anterior  cervical   44  per  cent. 

Submaxillary   36  per  cent. 

Epitroc'hlear 26  per  cent. 

Sublingual    25  per  cent. 

As  a  result  of  the  analysis  of  these  100  cases  he  finds  that  the  maxillary 
glands  commonly  attain  the  largest  size,  and  also  most  frequently  undergo 
su23puration.  In  all  cases  examined  on  the  second  and  third  day  of  the 
disease  the  enlargement  of  the  lymphatic  glands  was  well  marked. 

Scarlatinal  synovitis  (so-called  scarlatinal  rheumatism  or  pseudorheu- 
matism)  is  occasionally  met  with.  Ashby^  met  with  this  condition  in  2  per 
cent,  of  his  cases. 

Hodge  found  synovitis  in  117  out  of  3000  cases  studied,  or  3.3  per 
cent.     There  are  two  distinct  forms : — 

(a)   Simple  catarrhal  or  serous  synovitis. 

(h)   Suppurative  or  purulent  arthritis. 

The  streptococcus  pyogenes  has  been  found  in  both  forms  in  pure 
culture  and  combined  with  other  micro-organisms. 

This  complication  occurs  more  often  in  children  over  5,  and  is  rarely 
met  with  in  children  under  3,  according  to  Holt. 

The  symptoms  met  with  are:  Pains  in  the  affected  joints,  swelling, 
which  may  or  may  not  be  marked  with  slight  impairment  of  motion,  some 
redness,  and  a  slight  rise  in  temperature. 

Owing  to  an  effusion  of  serum,  large  joints,  such  as  the  knee  and 
shoulder,  remain  swollen  many  weeks.  When  suppuration  develops  in  the 
involved  joint,  Henoch  claims  that  it  is  due  to  emboli,  following  septi- 
caemia. 

The  Kidneys. — There  are  three  forms  of  involvement  of  the  kidneys  in 
scarlatina : — 

1.  Transient  febrile  albuminuria  and  the  interstitial  catarrhal  ne- 
phritis. 

2.  Septic  nephritis. 

3.  Post-scarlatinal  nephritis. 

Transient  albuminuria  occurs  in  three-fourths  of  all  cases  of  scarlet 
fever.  It  does  not  differ  from  a  "febrile  albuminuria"  seen  in  all  acute 
infectious  diseases  associated  with  high  temperatures.  It  has  no  special 
significance. 

Catarrhal  nephritis  not  infrequently  occurs  in  the  first  week  in  cases 
of  moderate  severity.  The  urine  contains,  besides  albumin,  degenerated 
epithelial  cells,  mucous  cylindroids,  and  rarely  epithelial  or  even  hyaline 
casts,  occasionally  a  few  red  and  white  corpuscles. 


^British  Medical  Journal,  1883,  vol.  ii,  p.  514. 


KCAJtLET    FEVER. 


615 


Clinically,  we  have  slight  evidence  of  oedema.  Pathological  changes 
frequently  take  place  witlioiit  a  trace  of  albumin  or  without  the  presence  of 
casts.     Such  cases  have  been  reported.^- 

Bepiic  Nephritis. — Where  the  scarlatinal  virus  causes  a  general  tox- 
aemia, and  we  have  grave  throat  symptoms  accompanied  by  necrotic  de- 
posits on  the  tonsils  and  pharynx,  there  are  always  swollen  glands.  Ne- 
phritis develops  from  the  intensity  of  the  infection  caused  mainly  by  the 
streptococcus  pyogenes.  In  many  instances  death  occurs  before  well-de- 
fined symptoms  of  nephritis  are  made  out.  In  such  cases  there  is  no 
dropsy  and  ursemic  symptoms  are  absent.  In  rare  instances  the  urine  is 
normal  during  the  entire  attack  until  a  post-niorteni  shows  the  existence 
of  nephritis. 


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Fig.    196. — Septic  Nephritis   from    Riverside   Ilospitiil. 

Post-scarlatinal  Nephritis. — When  the  acute  symptoms  subside  and 
nephritis  develops  it  is  called  post-scarlatinal  nephritis.  This  nephritis  is 
not  always  glomerular.  Jurgensen's  statement  that  the  effect  of  the  in- 
flammatory irritant  depends  not  only  upon  its  virulence  (toxicity),  but 
upon  the  length  of  time  during  which  it  acts  upon  a  given  local  site,  is 
extremely  interesting  and  important. 

The  symptoms  may  l)e  sudden,  although  if  daily  examinations  of  the 
urine  are  made  a  gradual  diminution  in  the  quantity  secreted  in  twenty-- 
four  hours  will  be  noted. 

The  child  who  has  seemed  a])parently  well  and  convalescing  becomes 
pale,  is  restless  and  irritable,  and  if  old  enough  complains  of  headaches, 


\  ^Corlett;      "Treatise  of  Infectious  Kxantlieinata,''  p.  201. 


616 


THE  INFECTIOUS  DISEASES. 


thirst,  and  loss  of  appetite.     Constipation  may  be  present.     Vomiting  is 
usually  an  early  symptom  of  nephritis. 

The  earliest  symptoms  of  nephritis  are:  rise  of  temperature,  occur- 
rence of  oedema,  however  slight,  involving  particularly  the  lower  eyelids, 
with  distinct  puffiness  of  the  eyes.  Sometimes  the  whole  face  is  swollen 
and  bloated.  The  feet  and  legs  are  oedematous,  so  also  the  scrotum. and 
penis  in  the  male,  and  the  labia  majora  in  the  female.  Such  oedema  may 
also  be  seen  on  the  dorsum  of  the  feet  and  upon  the  knuckles.  There  is 
pitting  on  pressure. 

BOUND  EPITHELIAL  CELLS         re0  bLOOD  CORPUSCLES 
PROBABLY  FROM  CONVOLUTED  [    i 

TUBULES  ,   ,^  f~-"r~--^    EPITHELIAL  AND 

SPUS  CAST 


EPITHELIAL 

CELL 
PROBABLY  FROM 
VAGINA 


HYALINE  CAST 


'    PUS  CORPUSCLES 
Fig.    197. — Drop  of  Urine  from  a  Case  of  Post-scarlatinal  Nephritis  seen  in 
consultation  by  the  Author.      (Original  chawing.) 

The  urine  is  greatly  diminished  in  quantity,  so  that  several  teaspoonfuls 
only  may  be  passed  in  twenty-four  hours.  The  reaction  is  acid.  Specific 
gravity  is  from  1.006  to  1.065,  the  latter  being  rare.  The  amount  of  urea 
is  under  2  per  cent.  Albumin  is  present  from  0.5  to  1  per  cent,  and 
higher.    The  diazo  reaction  is  of  no  value  in  scarlet  fever. 

Microscopically. — There  may  be  present  hyaline,  epithelial,  granular 
and  blood  casts,  fragmented  renal  epithelium,  white  and  red  blood-corpus- 
cles; the  latter  in  varying  numbers;  uric  acid  and  oxalic  acid  in  crystal- 
line and  amorphous  form,  and  more  or  less  granular  debris. 

Cases  are  seen  now  and  then  in  which  almost  normal  conditions  of  the 
urine  prevail  and  still  nephritis  exists. 

Nephritis  usually  exists  a  few  weeks,  although  obstinate  cases  may 
continue  for  months  and  even  years. 


SCARLET  FEVER.  617 

Great  care  sJiould  he  exercised  in  giving  the  prognosis  in  cases  of  post- 
scarlatinal nephritis.  Uraemia,  when  occurring  during  nephritis,  is  a  grave 
symptom.  It  is  usually  preceded  by  vomiting,  stupor,  and  peculiar  twitch- 
ings  of  the  facial  muscles. 

The  pulse  is  slow;  the  temperature  subnormal;  the  tongue  is  dry. 
Sometimes  just  the  reverse  exists  and  there  is  high  fever,  very  frequent 
and  small  pulse;  the  respirations  are  short  and  hurried,  and  the  skin  dry. 

Convulsions  may  develop,  clonic  in  character,  of  varying  intensity,  in- 
volving the  face  and  extremities  as  a  whole.  Sometimes  only  distinct 
groups  of  muscles  are  involved.  Cyanosis  is  marked,  complete  suppression 
of  urine  follows,  coma  ensues,  and  usually  these  cases  end  fatally. 

Anasarca  is  frequently  associated  with  or  subsequent  to  oedema.  We 
frequently  have  serous  exudations  into  the  serous  cavities — pleura,  pericar- 
dium, or  peritoneum.  CEdema  of  the  lungs,  sometimes  oedema  of  the  larynx, 
results,  and  is  usually  fatal.  Mayr  mentions  oedema  of  the  pia  mater  and 
ventricles  of  the  brain. 

The  Diagnosis. — When  fever  exists  accompanied  by  an  inflamed  throat 
and  an  eruption  over  the  body,  then  the  diagnosis  of  scarlet  fever  can  be 
made.  Later  on  we  have  desquamation.  The  most  characteristic  early 
symptoms  of  a  typical  scarlet  fever  are :  Intense  redness  of  the  faucial 
mucous  membrane,  sore  throat,  early  and  persistent  vomiting,  fever,  thirst, 
and  increased  pulse-rate.  The  tongue  is  very  characteristic — strawberry 
appearance.  (See  Plate  XXVIII.)  Sometimes  an  attack  of  scarlatina  is 
ushered  in  by  convulsions.  Older  children  complain  of  an  intense  headache. 
There  is  marked  constitutional  depression  and  aching  of  bones.  Von  Leube 
maintains  that  vomiting  occurs  more  often  as  an  initial  symptom  in  this 
than  in  any  other  disease,  excepting  pneumonia.  There  is  nothing  peculiarly 
characteristic  in  the  early  temperature  of  scarlet  fever.  It  remains  elevated 
after  a  sudden  rise,  and  subsides  gradually  by  lysis  toward  the  end  of  the 
first  week. 

Drug  Eruptions. — Great  care  must  be  taken  to  learn  if  a  child  has 
received  belladonna,  opium,  quinine,  or  antipyrin.  These  drugs  give  an 
eruption  similar  to  scarlet  fever.  We  should  always  learn  if  such  drugs 
have  been  given  before  making  a  positive  diagnosis. 

Course. — Scarlet  fever  usually  runs  its  course  in  about  six  weeks  from 
the  beginning  of  illness.  The  febrile  stage  usually  subsides  during  the  first 
week,  rarely  later  than  the  tenth  day.  It  is  spread  by  cases  in  the  early 
stages  of  the  disease.  Such  children  usually  complain  of  headache,  nausea, 
and  vomiting.  A  superficial  examination  or  a  careless  examination  of  these 
"spoiled  stomachs"  has  frequently  been  the  cause  of  the  spread  of  scarlet 
fever,  children  being  permitted  to  go  to  school.  In  the  pre-exanthematous 
type  the  diagnosis  is  difficult  unless  the  throat  is  carefully  inspected.     No 


618  THE  INFECTIOUS  DISEASES. 

child  should  be  permitted  to  attend  school  until  the  last  evidence  of  desqua- 
mation has  disappeared. 

Prognosis. — It  is  very  difficult  to  determine  the  outcome  of  a  case, 
especially  at  the  beginning  of  scarlet  fever.  A  mild  rash  may  have  serious 
complications  and  a  severe  rash  may  run  a  very  mild  course  without  com- 
plications. 

Individual  susceptibility  plays  an  important  part  in  forming  an 
opinion  as  to  the  outcome  of  any  case  of  scarlet  fever.  The  following 
symptoms  should  influence  an  unfavorable  prognosis:  continued  hyper- 
pyrexia; continued  vomiting;  delirium  or  other  cerebral  symptoms,  such 
as  convulsions  or  stupor;  an  irregular  anomalous  or  poorly  developed  rash, 
if  intense,  suggests  extreme  virulence;  an  extremely  rapid  and  feehle  or 
irregular  pulse.  Great  stress  should  always  be  laid  on  the  condition  of  the 
heart.  Other  complications,  such  as  broncho-pneumonia,  or  diphtheria,  or 
kidney  disease,  should  be  noted  as  very  serious  complications. 

Treatment. — Isolation  and  Care:  In  New  York  City  cases  of  scarlet 
fever  are  excluded  from  school  for  at  least  five  weeks,  or  until  desquamation 
is  complete  and  all  purulent  discharges  have  ceased.  If  quarantine  is  ob- 
served by  the  family,  children  and  others  who  have  had  the  disease  may 
return  to  school.  If  children  or  other  members  of  the  family  who  have 
not  had  scarlet  fever  are  immediately  removed  to  another  address,  they  may 
return  to  school  at  the  end  of  five  days  if  in  the  mean  time  they  do  not 
develop  the  disease,  but  they  must  present  a  special  school  certificate  issued 
by  the  department.  If  they  continue  to  reside  at  home,  they  cannot  return 
to  school  until  the  case  of  scarlet  fever  has  been  officially  discharged  by  the 
Department  of  Health. 

Hundreds  of  physicians,  students,  and  nurses  observe  cases  of  scarlet 
fever  without  coming  into  direct  contact  with  the  patient,  and  no  infection 
takes  place.  When,  however,  physicians  and  nurses  are  exposed  to  the 
patient's  cough  or  come  into  direct  contact  with  the  salivary  secretions  from 
the  nose  or  mouth,  then  such  persons  run  the  risk  of  infection. 

Hygienic  Treatment. — The  temperature  of  the  room  should  be  from 
68°  to  73°  F.^  Fresh  air  must  be  admitted;  hence  proper  ventilation  is 
imperative.  In  winter  the  patient  should  be  well  protected  from  draughts. 
Sunshine  is  imperative,  although  the  eyes  should  be  shielded  from  direct 
sunlight.  A  tepid  sponge-bath  can  be  given  every  morning,  and  also  in  the 
evening,  especially  if  there  is  profuse  perspiration.  The  child's  linen  should 
be  changed  once  a  day.  When  the  eruption  causes  itching,  the  body  should 
be  rubbed  with  cold  cream,  carbolated  vaseline,  or  the  following  recipe  is 
very  useful : — 

IJ  Calamine  1  drachm 

Ung.  aq.   rosse    1  ounce 

M.  et  ft.  ungt. 

Sig.:     Apply  over  the  body  once  or  twice  a  day. 


SCARLET  FEVER.  619 

Forchheimer  advises  the  addition  of  menthol,  1  per  cent.,  to  relieve 
itching.    This  can  be  added  to  the  above. 

Oeneral  Treatment. — Stimulate  ttie  Emunctories:  The  bowels  should 
always  receive  attention,  whether  constipated  or  not;  a  dose  of  calomel  or 
several  winegiassfuls  of  citrate  of  magnesia  or  villacabras,  in  wineglassful 
doses,  three  times  a  day,  will  be  found  very  serviceable. 

.Lemon  juice  in  the  form  of  lemonade  is  very  serviceable  in  stimulating 
the  secretion  of  urine,  and  also  for  quenching  thirst.  The  citric  acid  cer- 
tainly has  a  beneficial,  effect  on  the  throat. 

I  have  always  seen  the  best  results  from  l-eeping'  the  bowels  loose  and 
the  Iddneys  active.  That  we  eliminate  toxic  products  in  this  manner  no  one 
can  deny,  and  we  certainly  can  do  no  harm  by  this  preliminary  treatment. 

Fever. — The  use  of  tepid  water  as  an  antipyretic  measure  is  the 
safest  means  of  reducing  fever  without  depressing  the  heart.  Each  fever 
should  be  studied  by  noting  how  much  depression  is  caused  by  it — how  the 
child  stands  the  temperature.  If  the  child  appears  bright  and  cheerful 
and  there  is  little  constitutional  disturbance  from  high  fever,  then  cool 
sponging  or  tepid  packs  may  be  ample;  if,  however,  there  is  marked  de- 
pression, then  a  warm  bath  may  serve  our  purpose  much  better.  When  a 
bath  is  used,  the  child  should  be  immersed  in  a  tub  of  water  having  a  tem- 
perature  of  90°  F.,  and  after  the  patient  is  immersed  add  cold  water  or  ice 
until  the  temperature  of  the  water  is  reduced  to  80  F.  In  all  a  bath  should 
last  about  three  minutes,  not  longer  than  five  minutes.  It  is  important  to 
watch  the  pulse  while  the  child  is  in  the  bath.  The  temperature  should  be 
taken  before  and  about  ten  minutes  after  the  bath  to  note  the  fever.  We 
can  then  see  what  effect  has  been  produced.  Such  baths  may  be  repeated 
in  three,  four,  or  six  hours,  depending  on  the  individual  requirements. 

An  ice-cap  may  be  placed  on  the  head  after  the  bath. 

The  treatment  of  fever  is  of  the  greatest  importance.  When  there 
are  stupor,  drowsiness,  and  delirium,  the  tepid  bath  will  be  indicated. 
Cold  packs  and  cold  sponging  are  also  valuable.  Antipyrine,  phenacetine, 
and  quinine  are  extolled  by  some  and  condemned  by  others.  When  used 
they  should  always  be  combined  with  musk  or  camphor,  or  given  with  coffee 
to  counteract  the  well-known  cardiac  depression  caused  by  the  antipyretics 
belonging  to  the  coal-tar  series. 

In  the  treatment  of  high  temperature  in  scarlatina  and  infectious  dis- 
eases, injections  of  sulpho-carbolate  of  soda,  10  grains  to  a  pint  of  cool 
water  (temperature,  70°  F.),  is  one  of  the  best  means  of  reducing  fever. 
These  injections  should  be  repeated  every  three  or  four  hours.  (Read  also 
the  "Influence  of  Serum  on  the  Temperature,"  page  637.) 

Fever  caii  also  be  reduced  by  the  use  of  the  following  mixture : — ■ 


620  THE  INFECTIOUS  DISEASES. 

5   Tinet.  aconiti   20  drops^ 

Spir.  mindereri    2  ounces 

Syr.  limonis   1  ounce 

M.  Sig. :  TeasjXKjnful  every  hour  until  sA\-eating  is  produced,  for  a  child  5 
to  12  rears  old.     Younger  children  one-half  the  dose. 

Weak  Pulse. — ^When  the  first  soiind  of  the  heart  becomes  weak,  or  the 
two  sounds  lose  their  normal  tone,  stimulation  must  be  commenced.  The 
same  is  true  if  the  pulse  is  weak;  ^/loo  grain  of  strN'chnine  can  be  given 
every  three  hours,  or  oftener.  if  necessary.  It  must  be  borne  in  mind  that 
children  tolerate  strjx-linine  in  toxgemic  conditions  in  \Qvy  large  doses.  It 
is  a  good  |3lan  to  give  coffee  with  the  strA'Chnine  or  to  combine  it  with  caf- 
feine or  musk.  Digitalis  is  indicated  if  the  pulse  is  weak  and  of  low  ten- 
sion. It  should  not  be  used  continuoush',  as  it  irritates  the  stomach,  and 
in  its  stead  tincture  of  strophanthus  should  be  used.  Champagne  or  whisky 
is  tolerated  in  extreme^  large  doses.  Henoch  considers  camphor  one  of  the 
best  stimulants  when  given  hj^podermically  every  two  or  three  hours : — 

IJ^  Camphor     1  gram 

Ether   10  grams 

Sig. :    Use  hypodeiinically. 

Coma. — In  coma  the  snbcutaneous  use  of  sodium-caffeine-benzoate 
stunulat-es  the  heart  and  arouses  the  cliild  from  stupor.  It  also  stimulates 
diuresis.  When  bloody  urine  exists  in  addition  to  gallic  acid,  suj)rarenal 
extract  or  its  alkaloid,  adrenalin,  can  be  used  in  very  small  doses. 

Spartein  sulphate,  ^/4  to  %  grain,  injected  hj^odermically,  Avith  dis- 
tilled water,  is  useful  in  cardiac  weakness.  W^hen  meningeal  s}Tnptoms,  such 
as  delirium,  cannot  be  relieved  by  hot  baths  and  bromides  internally,  then 
the  application  of  several  leeches  behind  tlie  ears,  over  the  mastoid,  will  be 
very  useful. 

Xepliritis. — AVhen  the  first  symptom  of  nephritis  appears  we  must  aid 
the  kidneys,  skin,  and  bowels  by  eliminative  treatment.  In  this  manner 
only  can  the  blood-pressure  be  reduced.  The  child  must  be  kept  in  bed, 
well  blanket-ed.  The  diet  should  consist  of  milk,  milk  and  seltzer,  milk  and 
cereals,  and  buttermilk.  If  the  stomach  is  irritable,  then  the  milk  should 
be  peptonized.  When  extreme  repugnance  to  milk  exists,  then  chocolate 
may  be  substituted  or  some  vanilla  flavor  added  to  the  milk.  For  thirst 
give  whey,  lemonade,  or  orangeade.  To  stimulate  diaphoresis,  hot  baths 
aided  by  hot  packs  will  be  serviceable.  The  temperature  of  the  bath  should 
be  100°  to  110°  F.  The  child  is  immersed  from  five  to  ten  minutes.  The 
surface  of  the  body  must  be  continually  rubbed  during  the  bath.  The  pa- 
tient when  taken  out  of  the  bath  is  placed  between  hot  blankets  for  one 
hour,  so  as  to  aid  diaphoresis.  To  give  the  hot  pack  the  child  should  be 
wrapped  in  a  blanket  wrung  out  of  hot  water,  temperature  100°  F.,  and 


SCARLET  FEVER. 


621 


then  covered  with  a  dry  blanket,  over  which  is  placed  a  rubber  cloth.  The 
blanket  can  also  be  covered  with  oil-silk. 

The  pulse  should  be  watched  during  the  bath,  and  the  child  should 
at  once  be  removed  if  signs  of  weakness  appear. 

The  Hot-air  Bath. — Place  the  child  in  bed  and  cover  with  two  blankets. 
On  either  side  place  hot-water  bottles  or  hot  bags  of  sand  so  protected  that 
the  child  cannot  be  burned.  Over  these  place  a  rubber  cloth  or  a  raincoat. 
Over  the  rubber  place  another  blanket.     Sweating  occurs  very  easily  and 


Fig.  198. — Coffey's  Glass  Apparatus  Devised  for  Hypodermic  Saline 
Injections.  The  temperature  of  solutions  can  be  seen  and  regulated  by  the 
thermometer.  A  second  thermometer  shows  the  temperature  of  the  solution 
as  it  enters  the  body.  This  apparatus  can  also  be  used  for  colonic  flush- 
ings by  removing  the  needle  and  attaching  a  rectal  tube. 

very  quickly  in  this  manner.    In  an  emergency  the  ordinary  flat-iron  can  be 
used,  instead  of  the  hot-water  bottles,  for  a  hot-air  bath. 

Pilocarpin  and  jaborandi  are  such  cardiac  depressants  that  they  are 
merely  mentioned  to  be  condemned.  Nitroglycerine  is  very  valuable.  When 
a  general  dropsy  appears,  the  danger  of  effusion  into  the  serous  cavities 
must  be  borne  in  mind.  When  necessary  the  effusion  should  be  relieved  by 
aspiration.  The  quantity  of  urine  passed  is  the  most  important  point  which 
should  ffuide  us  in  determininjr  the  result  of  the  treatment. 


622  •  THE  INFECTIOUS  DISEASES. 

Liquids  should  not  be  forced  under  the  impression  that  we  are  stitn- 
ulatiag  diuresis.  Experience  has  taught  the  Staff  of  the  WHlard  Parker 
Hospital  that  we  can  stimulate  the  kidneys  by  careful  dieting,  and  by 
restricting  liquids.  The  following  case  occurred  during  my  service,  and 
will  illustrate  the  treatment. 

Mary  S.,  5  years  old.  was  ill  three  days  before  admission  to  the  Riverside  Hos- 
pital. Diagnosis:  Scarlet  fever.  Her  diet  consisted  of  milk  96  ounces  in  twenty- 
four  hours.  She  later  received  also  soup  and  cereals.  An  injection  of  10,000  anti- 
toxin units  was  given.  Three  days  later  the  child  complained  of  painful  joints.  The 
diet  was  restricted  to  milk. 

The  urine  showed  a  specific  gravity  of  1018,  contained  free  blood  and  abundant 
granular  casts.  Diagnosis:  Acute  renal  congestion.  Medication  consisted  of  agurin 
5  grains  every  four  hours,  nitroglycerin  ^/loo-grain  one-half  hour  before  hot  bath. 
Liquids  were  forced.  The  pulse  became  weak.  Strychnine  Vso-grain,  whisky  1  dram, 
was  ordered.  The  following  day  many  course  granular  casts  and  much  free  blood 
were  found  in  the  urine.     Whisky  was  discontinued. 

The  diet  until  this  time  consisted  of  96  ounces  milk  in  twenty-four  hours. 
Nephritis  and  oedema  present.  About  32  ounces  of  urine  was  voided  in  twenty-four 
hours.  The  following  day  liquids  were  restricted  to  22  ounces;  in  addition  cereals, 
bread,  prunes,  and  peaches  were  given.  The  total  urine  passed  within  the  twenty- 
four  hours  was  35  ounces.  Following  day  same  diet  was  given;  total  urine  passed 
was  40  ounces.     Thus  by  restricting  liquids  we  aided  diuresis. 

If  the  quantity  of  urine  increases  and  the  percentage  of  albumin  de- 
creases, then  our  patient  is  improving.  The  disappearance  of  blood  cor- 
puscles and  casts  denotes  improvement.  One  of  the  best  drugs  to  aid 
diuresis  is  diuretine,  to  be  given  in  doses  of  3  grains  for  a  child  two  years 
old,  and  gradually  increased  until  5  grains  per  dose  is  administered.  This 
drug  should  be  given  at  least  three  times  a  day  to  stimulate  the  kidneys. 
Another  drug  highly  recommended  by  Baginsky  is  acet-theocine.  It  can 
be  given  in  the  same  dosage  as  diuretine  and  the  dose  repeated  several  times 
a  day.  In  a  certain  class  of  cases  agurin  acts  well,  and  can  be  recom- 
mended, because  it  does  not  disturb  the  stomach.  Now  and  then  I  have 
noticed  that  marked  vomiting  followed  the  administration  of  almost  any 
drug  during  the  course  of  nephritis;  hence,  great  care  should  be  taken  not 
on  that  account  to  condemn  a  drug  during  the  course  of  nephritis  with 
toxic  or  ursemic  sjnnptoms. 

Vulvo-vaginitis  Following  Scarlet  Fever. — At  the  Eiverside  Hospital 
during  the  summer  of  1903,  out  of  100  cases  of  scarlet  fever  there  were  15 
cases  suffering  with  vulvo-vaginitis.  In  these  there  was  a  well-marked 
purulent  discharge  upon  the  deeper  parts  of  the  vulva  and  at  the  vaginal 
opening,  with  some  redness  and  irritation.  With  this  there  was  a  distinct 
rise  of  temperature  and  some  constitutional  disturbance.  The  cases  all 
yielded  promptly  to  treatment,  proving  especially  amenable  to  simple 
astringent  solutions  rather  than  to  more  active  germicides.^ 

^  Reported  to  me  by  Dr.  G.  L.  Nicholas,  Resident  Physician. 


SCARLET  FEVER.  623 

It  is  not  uncommon  to  find  cases  of  vulvitis  and  also  vaginitis  occurring 
in  the  scarlet-fever  wards  for  which  there  is  no  adequate  explanation. 

Vulvo-vaginitis  as  seen  at  the  Riverside  Hospital  occurs  as  a  distinct 
complication  to  scarlet  fever.  "When  it  occurs  it  shows  a  distinct  rise  of 
temperature  and  also  a  peculiar  constitutional  disturbance.  When  this 
is  contrasted  with  the  symptoms  of  a  catarrhal  otitis  the  similarity  of  both 
conditions  must  be  apparent.  Not  only  do  we  have  similar  bacteriological 
findings,  but  the  infection  manifests  itself  in  a  rise  of  temperature  and 
general  systemic  disturbance. 

While  an  occasional  case  of  true  gonorrhoeal  disease  may  arise  in 
which  the  Neisser  gonococcus  will  be  found,  from  a  large  clinical  experience 
in  both  hospital  and  private  practice,  I  must  say  that  such  cases  are  very 
exceptional. 

Prognosis. — The  prognosis  is  usually  good,  although  we  must  bear  in 
mind  that  if  these  cases  are  neglected  serious  results  may  follow.  Infection 
may  spread  from  the  urethra  into  the  bladder  and  from  the  bladder  into 
the  ureters,  and  infect  the  kidneys. 

Hygienic  Treatment. — In  this  disease  more  than  in  any  other  the 
strictest  attention  to  hygienic  rules  is  demanded.  If  it  is  an  infant  that 
is  so  afflicted,  the  pads  should  thoroughly  cover  the  vulva  and  be  saturated 
with  a  weak  solution  of  bichloride.  This  pad  should  be  adjusted  with  the 
aid  of  a  T-binder.  If  there  is  severe  itching  from  excoriation  and  the  child 
has  a  tendency  to  scratch,  the  hands  should  be  guarded  so  that  the  infection 
cannot  be  carried  from  the  genital  tract  to  the  eyes. 

Local  Treatment. — Labarraque's  solution  is  a  very  valuable  remedy. 
It  may  be  used  in  a  5  per  cent,  solution.  My  plan  has  been  to  add  about 
1  ounce  of  chlorine  water  to  1  pint  of  lukewarm  water  and  irrigate  morn- 
ing and  evening,  noting  the  effect.  If  the  discharge  is  not  lessened  thereby, 
the  injection  should  be  given  three  times  a  day. 

Astringent  solutions,  such  as  sulpho-carbolate  of  zinc,  sulphate  of  zinc, 
or  sulphate  of  copper,  using  1  grain  to  the  ounce,  are  useful.  When  there 
is  intense  itching  it  is  a  wise  plan  to  instill  a  2  per  cent,  ichthyol-glycerin 
solution  into  the  vagina  after  the  same  has  been  thoroughly  washed  with 
one  of  the  above  astringent  solutions. 

Argj^rol,  25  per  cent,  solution,  has  been  used  as  an  injection  several 
times  a  day  with  remarkable  success  at  the  Willard  Parker  Hospital  by 
the  resident  staff. 

The  vaccine  treatment  consists  in  injections  of  gonococcus  vaccine. 
These  injections  are  given  subcutaneously  in  doses  of  50  million  and  re- 
peated daily  until  1000  million  dead  bacteria  have  been  injected.  There 
is  no  specific  action  following  these  injections.  My  experience  in  some 
cases  has  been  good,  in  others  disappointing.  The  discharge  was  diminished ; 
in  some  cases  it  disappeared.    The  gonococcus,  however,  persisted. 


634  THE  INFECTIOUS  DISEASES. 

Endocarditis  or  Pericarditis. — The  heart  requires  careful  watching, 
especially  if  symptoms  of  rheumatism  appear.  Sudden  death  will  frequently 
occur  from  heart-failure. 

A  case  of  this  kind  was  seen  by  me  in  consultation  with  Dr.  S.  Straus,  of  New 
York  City,  in  which  a  child  desquamating  with  scarlet  fever  had  myo-  and  endo- 
carditis. There  was  a  general  anasarca.  The  pulse  became  very  weak  during  the 
hot-air  bath.  The  child  died  suddenly.  It  is  very  apparent,  therefore,  that  the 
hot-air  bath  is  not  without  its  dangers. 

Otitis} — The  escape  of  pus  from  the  external  auditory  canal  is  by  no 
means  rare.  The  extension  of  a  bacterial  infection — streptococcus  inflam- 
mation— from  the  pharynx  through  the  Eustachian  tube  can  sometimes  be 
aborted  by  local  treatment.  Too  great  stress  cannot  be  laid  on  the  active 
antiseptic  treatment  of  the  nasopharynx  as  a  means  of  prophylaxis.  When 
earache  occurs,  no  matter  how  slight,  then  the  ears  should  be  examined. 
It  is  better  to  call  an  aurist  to  make  sure  of  the  diagnosis  and  treatment, 
rather  than  risk  the  dangers  of  mastoid  inflammation,  with  the  possible 
extension  of  a  meningitis  and  a  fatal  outcome.  Until  then,  local  treatment, 
such  as  the  application  of  a  hot-water  bag  to  the  ear,  or  cotton  inserted  into 
the  ear,  will  afford  temporary  relief.  The  danger  of  using  cocaine  should 
not  be  forgotten,  although  it  is  a  valuable  remedy,  When  pus  is  evident, 
as  shown  by  the  bulging  of  the  membrane,  then  a  paracentesis  should  be 
•performed,  and  the  cavity  irrigated  with  boric  acid  solution,  or  1  part  of 
hydrogen  peroxide  and  5  parts  of  sterile  water.  The  ear  should  not  be 
packed  with  gauze,  but  should  be  permitted  to  discharge  and  drain  freely. 
Eestorative  treatment,  such  as  has  been  previously  mentioned  in  conjunc- 
tion with  nephritis  in  this  chapter,  is  indicated. 

Salt-free  Diet.^ — ^When  the  kidneys  are  affected,  their  activity  is 
diminished,  and  an  excess  of  salt  is  stored  in  the  tissues.  As  each  molecule 
of  salt  requires  a  certain  quantity  of  water  to  hold  it  in  solution,  such  water 
will  be  abstracted  from  the  tissues,  giving  rise  to  the  dropsical  condition. 
By  giving  a  diet  which  is  free  from  salt,  we  can  decrease  the  oedema. 

Generally  speaking,  during  the  febrile  stage  and  until  the  end  of  the 
second  week,  an  exclusive  liquid  diet  of  milk  or  milk  and  barley  water 
should  be  given.  If  milk  is  not  well  digested,  then  whey  should  be  tried 
(see  "Dietary").  Later,  beef  soup,  mutton  or  chicken  broth,  buttermilk, 
all  gruels,  fruits,  fruit  jellies,  toast,  weak  tea,  weak  coffee,  cocoa,  and 
chocolate.  For  thirst — Appollinaris,  Vichy,  and  lemonade.  The  tendency 
to  nephritis  seems  to  be  lessened  by  giving  our  patients  a  milk  diet ;  hence 
this  fact  must  be  borne  in  mind.  Steak  juice  and  egg  albumin,  diluted 
with  water,  can  be  given  later  on. 


^  Read  also  chapter  on  "Acute  Otitis  Media." 
^L'Echo  Medical  du  Nord,  January  20,  1907,  p.  25. 


SCARLET  FEVER. 


625 


Restorative  treatment,  such  as  iron,  strychnine,  malt  extract,  and  cod- 
liver-oil,  should  be  given  after  the  symptoms  of  nephritis  subside.  The 
child  should  be  kept  well  protected  for  at  least  two  months  after  the  first 
symptoms  appear. 

As  soon  as  the  temperature  falls  to  the  normal  point  we  can  give : — 

IJ.  Mist,  ferri  et  ammonii  acetatis, 

Glycerini  aa  1  fluid  ounce 

Aquse    q.   s.   ad  4  fluid  ounces 

M.     Sig. :     A  teaspoonful  or  more  every  three  hours,  in  water. 


DATES  OF  OBSERVATIONS 

4 

5 

6 

7 

8 

9 

10 

Cent. 

Fahr. 

AMiPM 

am:pm 

ANlPKl 

am:pm 

AMiPM 

am:pm 

AM'.PM 

41°" 
40°~ 

.8 
•6 

; 

•8 

•8 
•6 

■104" -2 

: 

39°" 

•8 
•6 

■103° -^ 

\h 

•/* 

A 

•8 
i02°-* 

I 

1 

^ 

\A 

•  1 

38°" 

•8 
•6 

-101°- » 

'■: 

V 

\;^ 

/ 

V' 

•8 
•6 

-100°- 2 

■• 

03 

\ 

37  °~ 

o 
6  &. 

T-t      W 

< 

-M    • 

•8 
•6 

-99°- 2 

CD   • 
p— »• 

•  8 
•6 

g  : 

36° 

-9»  -t 

fi  • 

•8 
•0 

o'  i 

-97  -2 

1/ 

•8 
•  6 

-96" -2 

- 

Pulse 
per  minute 

liespimtiona 
per  mviute 

^00 

N(0 

Fig.    199. — ^Temperature  Chart  from  a  Case  of  Scarlet  Fever  Treated  with 
Antistreptococcus  Serum.     (Original.) 

Or  Basham's  mixture  may  be  given : — 

IJ  Tinct.  ferri  chloridi, 

Acidi  acetici  dil aa  1  fluid  drachm 

Liq.  ammonii  acetatis    6  fluid  drachms 

Aquse    q.  s.  ad  6  fluid  ounces 

M.     Sig.:     Tablespoonful  three  times  daily  for  a  child  six  years  old. 

40 


626 


THE  INFECTIOUS  DISEASES. 


Serum  Treaimewi^Antistreptococcus  serum  has  been  extensively  used. 
It  has  its  opponents  and  some  who  extol  its  virtues.  Baginsky^  reports-  a 
series  of  48  cases  treated  with  serum,  of  which  7  were  fatal,  a  mortality  of 
14.6  per  cent. 

A  clinical  study  of  the  value  of  antistreptococcus  serum  was  reported  by 
me^  in  a  paper  read  before  the  Section  on  Pediatrics  of  the  New  York 
Academy  of  Medicine. 


200. — Method  of  Kasal   Syringing  emploAed  in  tlie  Scarlet  Fever 
Ward  of  the  Riverside  Hospital.      (Original.) 


Antistreptococcus  serum  (Aronson's^)  was  sent  to  me  in  the  winter 
of  1902-1903.  The  serum  proved  very  successfitl  in  a  series  of  cases  in  my 
private  practice.* 

Through  the  courtesy  of  Professor  Escherich  I  saw  a  number  of  cases 
that  were  treated  by  Moser's  antistreptococcus  serum  at  the  Children's  Hos- 
pital in  Vienna  while  in  Europe  in  May,  1903. 

All  of  these  serum  cases  did  remarkably  well.    I  was  impressed  by  the 


^  Berlin,  klin.  Woch.,  1896,  No.  33,  p.  340. 
^  "Value  of  Antistreptococcus  Serum,"  May  12,  1898. 

'  I  am  indebted  to  Messrs.   Sohering  &  Glatz  for   sending  me  sufficient  serum 
for  clinical  trial. 

*New  York  Medical  Record,  March  7,  1903. 


SCARLET  FEVER.  627 

excellent  results,  especially  by  the  distinct  fever  crisis,  after  the  necessary 
dose  of  serum  was  injected. 

The  preceding  chart  is  the  record  of  a  case  occurring  in  my  private 
practice. 

The  specific  action  of  antitoxin  in  diphtheria  is  far  greater  compara- 
tively than  the  action  attained  from  the  use  of  antistreptococcus  serum. 

The  Temperature. — The  effect  of  the  serum  on  the  temperature  shows 
that  it  did  inhibit  bacterial  products.  Within  twelve  to  twenty-four  hours 
after  the  serum  injection  I  have  seen  a  distinct  crisis  in  the  temperature. 
In  other  cases  the  temperature  was  gradually  reduced  by  lysis.     (Fig.  199.) 

Another  interesting  observation  in  most  cases  is  the  disappearance, 
almost  melting  away,  of  the  necrotic  membranes  after  the  fourth  day.  The 
glands  of  the  neck  were  swollen  and  subsided  with  the  disappearance  of  the 
throat  manifestations.  The  vital  point  consisted  in  a  strengthening  diet  in 
addition  to  strict  hygiene.  I  feel  warranted  in  advocating  the  use  of  this 
serum  in  the  treatment  of  scarlet  fever. 

Medicinal  Treatment. — The  Throat:  When  children  are  old  enough 
to  use  a  gargle  they  should  be  given  a  mild  antiseptic  solution,  such  as  table- 
salt  solution,  using  a  pinch  of  salt  to  a  wineglassful  of  lukewarm  water. 
Gargle  every  hour. 

A  spray  consisting  of  normal  saline  solution  directed  against  the 
pharynx  and  tonsils  every  hour  is  useful.  If  spraying  is  difficult,  then  the 
throat  may  be  swabbed  with  cotton  dipped  in  saline  solution.  High  tempera- 
ture will  frequently  subside  if  the  nasopharynx  is  properly  irrigated. 

The  septic  accumulations  are  very  serious  and  cause  profound  toxaemia 
unless  cleansed  thoroughly. 

Tincture  of  iodine  or  Lugol's  solution  carefully  applied  to  the  tonsils 
and  pharynx,  once  only,  is  advised.  Local  applications  of  50  per  cpnt. 
resorcin  solution  in  alcohol,  applied  on  cotton  several  times  a  day,  are  also 
advised. 

Nasal  Douching. — My  preference  has  always  been  for  mild  saline 
douches.  Hold  the  child  firmly  and  cleanse  the  nares  with  a  nasal  tip 
attached  to  a  fountain  syringe,  at  a  height  of  no  more  than  two  feet.  Per- 
manganate of  potash,  several  crystals  to  a  pint  of  water,  is  very  good  when 
there  is  foetor. 

I^  Natrium  sozoiodol, 

Flor.  sulphur    of  each,  equal  parts. 

M.     For  insuflQation  into  the  nostril  three  or  four  times  a  day. 

This  seemed  to  exert  a  very  beneficial  effect  on  the  necrotic  tissue, 
causing  a  clearing  of  the  throat. 

If  the  treatment  causes  nausea  or  vomiting,  then  the  sozoiodol  natrium 
can  be  given  internally  in  the  following  manner : — 


638  THE  INFECTIOUS  DISEASES. 

I^  Natrium  sozoiodol    2.0 

Aquae 100.0 

M.     Sig.:     Teaspoonful  every  hour. 

Swollen  Lymph  Glands. — In  septic  scarlet  fever  with  necrotic  pseudo- 
membranes  in  the  throat,  the  adjacent  Ij^mph  glands  will  he  swollen. 

At  times  there  is  an  extensive  oedema  and  infiltration  extending  into 
the  glottis,  which  can  result  in  asphyxia. 

Such  cases  will  be  benefited  by  the  use  of  thorough  inunctions  of 
Crede  ointment.^  It  must  be  distinctly  understood  that  no  result  will  be 
noted  unless  the  ointment  is  rubbed  into  the  swollen  glands  at  the  angle 
of  the  jaw  for  at  least  fifteen  minutes.  This  can  be  repeated  several  times 
a  day. 

I  also  have  used  inunctions  along  the  spine  to  promote  absorption  over 
a  greater  area.    This  has  proven  very  eflBcacious  in  many  cases. 

Forchheimer  advocates  the  use  of  sterile  normal  salt  solution  subcu- 
taneously.  This  is  done  to  stimulate  diuresis  and  also  to  aid  in  the  elimi- 
nation of  toxins.  In  my  own  practice  I  have  found  marked  benefit  from 
irrigating  the  colon  with  a  rectal  tube  introduced  about  six  inches,  using 
several  pints  of  normal  salt  solution  at  a  temperature  of  100°  to  105°  P. 
This  is  a  very  rapid  and  convenient  method  in  an  emergency,  especially 
when  one  is  hampered  by  necessary  irrigators  and  needles,  as  we  require 
only  an  ordinary  fountain  syringe  and  the  rectal  catheter  connected  with  it. 

Immunity  from  Diphtheria. — An  injection  of  500  to  2000  antitoxin 
units  will  confer  immunity  from  diphtheria  in  a  case  of  scarlet  fever. 

Diphtheria. — If  diphtheria  complicates  scarlet  fever,  then  the  usual 
treatment  of  diphtheria  should  be  instituted  (see  chapter  on  "Diphtheria"). 

At  the  Eiverside  Hospital  every  case  of  scarlet  fever  is  injected  with 
500  to  1000  diphtheria  antitoxin  units  as  a  prophylactic  measure.  By  this 
means  Dr.  Eichardson  believes  that  we  have  reduced  the  complication  of 
diphtheria  in  about  50  to  75  per  cent,  of  all  cases. 

Septic  Scarlet  Fever. — In  septic  cases  where  the  system  is  overwhelmed 
with  toxin,  we  frequently  have  extreme  prostration,  rapid  pulse  rate,  and 
temperature  ranging  between  100°  and  101°.  In  other  cases  the  tempera- 
ture may  rise  to  104°  or  105°,  all  depending  on  the  disturbance  of  the 
thermic  center.  It  is  in  this  class  of  cases  that  we  welcome  almost  any 
remedy. 

Convalescent  Human  Blood-serum. — The  intramuscular  injections  of 
convalescent  blood-serum,  as  a  therapeutic  agent,  have  been  extensively 
used  both  in  this  country  and  abroad.  It  is  especially  indicated  where 
septic  conditions  exist.  I  have  seen  cases  of  septic  scarlet  fever  at  the 
Willard  Parker  Hospital  injected  with  200  to  300  c.c.  of  serum  from  cases 


^  Schering  &  Glatz,  agents.  New  York  City. 


SCARLET    FEVER.  G29 

in  tlic  fourtli  and  fifth  weeks  of  convalescence.^  Within  twenty-four  hours 
after  the  injection  a  rapid  full  in  temperature  is  noted.  Sometimes  the 
temperature  falls  by  lysis.  'I'iiis  iherapcutie  measure  is  sufficiently  impor- 
tant to  encourage  its  use  whenever  possible.  Intravenous  injections  of  0.2 
to  0.3  gramme  neosalvarsan  rendered  very  good  results.  Out  of  12  hopeless 
cases  injected,  7  recovered. 

Since  the  introduction  of  neosalvarsan,  the  technique  of  preparation 
has  been  greatly  simplified.  The  neosalvarsan  is  dissolved  in  sterile  water, 
and  is  ready  for  injection.  For  a  young  infant  under  1  year  0.1  gramme  of 
neosalvarsan  is  dissolved  in  20  cubic  centimeters  of  sterile  water  and  injected 
into  the  jugular  vein.  An  older  child,  2  to  4  years,  may  receive  0.2  gramme 
of  neosalvarsan  in  40  cubic  centimeters  of  sterile  water.  Owing  to  the  small 
size  of  the  median  basilic  vein  at  the  bend  of  the  elbow,  it  may  be  necessary 
to  incise  the  skin  and  expose  the  vein  to  insert  the  needle.  My  preference 
has  been  to  inject  into  the  jugular  vein.  The  technique  is  simple  if  the  neck 
is  properly  supported.  No  systemic  effect  is  noticeable  after  these  injections. 
By  using  the  neosalvarsan  we  avoid  the  complicated  preparation  which  was 
necessary  in  the  use  of  salvarsan. 

An  illustration  of  the  technique  of  injecting  into  the  median  basilic 
vein  may  be  seen  on  page  536. 

A  series  of  cases  of  severe  scarlet  fever^  in  which  profound  toxEemia 
existed  were  injected  with  neosalvarsan.  In  a  case  of  severe  noma  compli- 
cating scarlet  fever  an  injection  of  0.2  gramme  of  neosalvarsan  was  given 
with  excellent  results. 

There  is  no  specific  drug  or  serum  in  use  today,  so  that  too  much 
should  not  be  expected  from  neosalvarsan. 

Transfusion. 

This  therapeutic  measure  is  indicated  in  a  series  of  devitalized  cases 
wherein  the  blood-supply  is  weakened.  Septic  cases,  no  matter  wdiat  the 
cause,  are  adapted'  to  this  form  of  therapy.  ■  Infants  suffering  with  maras- 
mus and  inanition  respond  to  this  form  of  treatment.  In  cardiac  weak- 
ness following  or  during  the  course  of  an  influenzal  penumonia  I  have  had 
exceedingly  good  results  from  its  use.  I^ikowisc,  this  procedure  has  served 
me  in  infants  weakened  by  prolonged  diphtheria,  the  toxic  type,  as  well  as 
in  toxic  forms  of  scarlet  fever. 

This  method  consists  briefly  in  withdrawing  from  the  donor,  with  tlie 
aid  of  a  blunt-pointed  steel  needle  and  a  record  syringe,  as  many  ounces  of 
l)lood  as  desired  for  the  transfusion.     To  prevent  coagulation  of  the  blood 

^  These  cases  were  injected  during  my  service  by  the  StatV  of  tlie  Research 
Laboratory. 

=  Reported  at  the  International  Medical  Congress,  London,  1913,  Section  on 
Diseases  of  Children, 


630  THE    INFECTIOUS   DISEASES. 

a  citrate  of  soda  solution  is  added  to  it,  and  the  whole  kept  at  blood  heat, 
in  a  sterile  beaker  until  needed,  or  with  the  aid  of  TJnger's  apparatus  direct 
transfusion  can  be  done.  Hust,  in  1914,  used  a  human  blood  transfus.ion 
by  adding  citrate  of  soda  and  glucose  to  the  blood.  Citrated  blood  was 
also  recommended  by  Weil  in  1914,  who  used  1  per  cent,  sodium  citrate 
solution.  E.  Lewisohn  found  that  0.2  per  cent,  solution  of  sodium  citrate 
will  keep  the  blood  fluid.  His  experiments  with  human  blood  transfusion 
were  performed  at  the  Mt.  Sinai  Hospital  in  New  York. 

The  important  fact  gleaned  from  these  experiments  is  that  the  addi- 
tion of  the  citrate  of  soda  prevents  clotting. 

The  technique  of  the  injection  has  been  described  by  Dr.  A.  Zingher 
in  the  Medical  Eecord,  March  13,  1915.  A  suitable  donor  must  be  chosen. 
We  have  encountered  no  dfficulty  in  procuring  one  of  the  parents  or  uncles 
to  give  eight  to  twelve  ounces  of  blood.  The  donor  must  be  free  from 
syphilis  or  tuberculosis.  If  time  permits,  and  the  case  is  not  a  desperate 
one,  we  should  determine  if  the  serum  of  the  donor  agglutinates  or  hemo- 
Ij'zes  the  patient's  red  blood-cells  or  vice  versa.  This  method  is  described 
by  Ottenberg  and  Epstein.  In  emergency  cases  as  met  with  by  me  it  was 
impossible  to  take  the  time  to  study  the  agglutination  and  hemolysis  of  the 
donor's  blood.  Ottenberg  states  that  while  it  is  better  to  test  each  donor's 
blood,  he  believes  that  danger  exists  inj  but  2  per  cent,  of  all  cases,  or  one 
in  fifty. 

The  technique  of  transfusion  is  so  simple  that  it  can  be  successfully 
carried  out  in  most  cases  by  the  general  practitioner  in  the  patient's  home 
without  any  elaborate  paraphernalia.  IBiut  all  must  be  done  with  sterile 
and  aseptic  technique. 

The  donor  is  placed  in  a  recumbent  position.  A  piece  of  rubber  tubing 
and  an  artery  clamp  acts  as  a  tourniquet  above  the  elbow.  To  a  30  c.c. 
record  syringe  a  steel  needle  one  and  one-half  inches  long  is  attached  and 
inserted  into  the  tense  median  cephalic  vein.  A  syringeful  of  blood  is 
aspirated.  The  needle  is  left  in  situ.  The  barrel  of  the  syringe  detached, 
and  the  blood  quickly  emptied  into  a  large  beaker  containing  two  and  one- 
half)  c.c.  of  a  10  per  cent,  solution  of  sodium  citrate.  To  keep  the  needle 
free,  with  the  aid  of  a  small  record  syringe,  inject  a  few  drops  of  a  1  per 
cent,  sodium  citrate  solution.  Too  rapid  depletion  is  not  safe,  and  may 
result  in  a  sudden  cerebral  anemia.  It  is  much  safer  to  allow  the  circula- 
tion of  the  donor  to  be  re-established  before  withdrawing  the  second  syringe- 
ful of  blood. 

After  each  addition  of  blood  to  the  citrate  solution  the  beaker  must  be 
thoroughly  shaken,  in  order  that  the  citrate  may  become  thoroughly  mixed 
with  the  blood. 

Choice  of  Vein  in  an  Infant. — There  are  four  places  adapted  for  this 
method:  (1)  the  median  cephalic,  (2)  the  median  bacillic,  (3)  the  jugular, 
and  (4)  the  longitudinal  sinus. 

The  longitudinal  sinus  has  been  suggested  by  Tobler  and  Helmholz. 


SCARLET    FEVER.  G31 

Marfan  as  early  as  1898  advised  the  use  of  this  route  for  the  intravenous 
administration  of  salt  solution.  Owing  to  the  ease  with  which  one  can 
enter  the  sinus  through  the  anterior  fontanelle  it  seems  as  though  Nature 
had  left  this  opening  as  an  emergency  for  this  course  of  treatment  in  infants. 

In  many  of  my  cases  the  median  cephalic  vein  was  used.  This  being 
a  very  small  vein  in  infante,  it  was  necessary  to  make  a  small  incision  and 
expose  the  vein  in  order  to  inject  the  blood.  The  patient  receives  the  blood 
directly  into  the  vein. 

Baby  W.,  born  Jan.  4,  1915,  was  asphyxiated  at  birth  and  resuscitated  with  the 
aid  of  a  pulmotor.  It  was  a  forceps  case.  Suffered  cerebral  haemorrhage.  Prognosis 
hopeless.  Received  breast-feeding,  but  was  so  weak  that  its  first  cry  was  noted  when 
1  month  old.  Always  regurgitated  or  vomited  its  food.  The  infant  when  I  first  saw 
it  was  7  weeks  old,  and  weighed  714  pounds.  It  had  an  irregular,  thready,  and  in- 
termittent pulse,  was  fed  with  difficulty,  was  listless  and  cyanotic.  The  stools  con- 
tained undigested  particles  of  cheese  and  mucus.  The  circulation  was  bad,  extremi- 
ties cold,  the  heart  soimds  were  feeble.  Eight  ounces  of  citrated  blood  were  transfused. 
An  uncle  of  the  infant  was  the  donor.  The  blood  was  injected  in  the  median  cephalic 
vein.  There  was  slight  improvement  in  the  color  of  the  skin  during  the  transfusion. 
On  the  following  day  the  infant  was  brighter,  had  more  color  in  the  cheeks  and  ears, 
began  to  notice  objects,  and  appeared  more  natural.  Gained  6  ounces  during  the 
first  week  after  the  transfusion.  The  second  week  gained  6  ounces  more.  The  child 
is  now  over  2  years  old,  and  normal  in  every  respect. 

Eegarding  the  effect  of  normal  blood  during  an  acute  infectious  dis- 
ease much  has  yet  to  be  learned.  In  some  instances  the  blood  of  con- 
valescents from  scarlet  fever^  wa&  utilized  for  both  intravenous  and  intra- 
muscular injections  in  the  severer  forms  of  scarlet  fever,  and  it  seems  that 
tliere  is  more  specific  bactericidal  power  in  the  hlood  of  a  convalescent  than 
there  is  in  the  normal  human  blood.  This  leads  Ottenberg  to  state  that 
the  blood  of  persons  who  have  recovered  from  an  infectious  disease  or  who 
have  been  artificially  inununized  has  specific  properties  not  only  in  the 
antibodies  of  the  plasma,  but  possibly  also  in  the  cells. 

Observation  and  Treatment  of  the  Donor. — -The  pulse  of  the  donor 
requires  careful  supervision,  whether  we  draw  blood  with,  a  syringe  or 
othenvise ;  less  supervision,  however,  with  the  syringe  method.  Most  of  the 
men  wdiom  I  have  seen  did  best  when  they  were  blindfolded,  as  the  sight  of 
blood  invariably  caused  nausea,  and  sometimes  syncope.  The  pulse  is 
invariably  slow^ed,  and  should  be  watched  for  signs  of  collapse.  We  in- 
variably stimulate  the  circulation  after  withdrawing  eight  ounces  or  a  pint 
of  blood  by  giving  the  donor  one-half  pint  of  milk  with  the  yolk  of  egg 
added,  or  warm  broth,  or  coffee,  to  which  the  yolk  of  Qgg  is  added.  Xo 
other  stimulation  was  necessary.  It  is  important  to  have  the  donor  rest  at 
least  an  hour  after  withdrawing  the  blood. 

Influence  of  Fever. — A  decided  drop  in  the  temperature  followed  in 
each  of  six  transfusions  (transfused  cases).  In  one  instance  the  tempera- 
ture dropped  from  104°  to  100°  within  six  hours.    In  another  instance  the 

^Park  and  Zingher,  Treatment  of  Scarlet  Fever  with  Fresh  Blootl  from  Con- 
vales^eent  Patients:    New  York  State  Journal  of  Medicine,  March,  1915. 


632  THE    INFECTIOUS   DISEASES. 

temperature  dropped  three  degrees  within  six  hours  by  lysis.  This  decided 
antithermic  effect  could  be  accounted  for  in  no  other  way  excepting  directly 
due  to  the  influence  of  the  fresh  blood-supply.  Ottenberg  and  Libman  have 
made  a  similar  observation  on  the  influence  of  transfusion  on  fever.  "Of 
particidar  interest  is  the  transfusion  on  the  fever  which  is  such  a  conspicu- 
ous feature  of  a  large  number  of  cases  of  pernicious  anemia.  It  has  been 
found  in  over  60  per  cent,  of  the  cases  (in  one  report  as  high  as  80).  In 
5  of  the  6  febrile  cases  we  investigated  the  fever  disappeared  after  trans- 
fusion. This  phenomena  is  not  peculiar  to  this  form  of  anemia^  for  among 
16  other  cases  of  anemia  due  to  a  variety  of  causes  (including  infections) 
febrile  before  transfusion,  8  became  afebrile  after  it.  These  observations 
lend  strong  support  to  the  view  that  there  exists  a  fever  dependent  upon 
anemia  as  such,  the  so-called  anemic  fever.  Transfusion  is  the  best  remedy 
for  pernicious  anemia;  it  never  cures,  but  it  leads  to  remissions  in  about 
half  the  cases." 

The  Advantages  of  Syringe  Transfusion. — ^There  are  decided  advan- 
tages in  the  direct  or  syringe  method  as  advised  by  Lindeman,  Zingher,  and 
others.  There  is  no  traumatism,  no  pain,  and  a  decided  absence  of  shock. 
The  most  important  point,  however,  is  that -the  exact  amount  transfused 
is  known.  Another  advantage  of  the  syringe  method  is  that  the  donor's  blood 
can  be  removed,  mixed  with  an  anticoagulant  such  as  citrate  of  soda,  and 
then  taken  to  the  patient.  This  majr  be  an  important  factor  in  securing 
blood  from  a  donor  who  is  sensitive  about  going  to  a  hospital  or  who  does  not 
care  to  come  in  immediate  contact  with  the  recipient.  This  latter  may  be 
an  important  point  if  the  patient  (recipient)  has  an  acute  infectious  dis- 
ease which  coidd  be''  transmitted  to  the  donor. 

From  the  communication  here  presented  I  feel  justified  in  making  the 
following  deductions  :— 

1.  That  this  is  a  very  useful  method  of  therapeutics. 

2.  That  it  can  be  used  in  the  private  house  as  well  as  the  hospital. 

3.  That  very  little  assistance  is  required. 

4.  That  manj^  marasmic  and  underfed  infants,  and  especially  cases  of 
secondary  anemia,  are  adapted  to  this  treatment. 

One  striking  point  was  forcibly  brought  out  in  the  marasmic  case 
under  consideration.  The  infant's  temperature  was  subnormal,  the  extremi- 
ties cold.  A'  general  cyanosis  was  evident  in  the  lips  as  well  as  fingernails 
and  toenails.  .  The  circulation  was  stagnant.  Within  a  few  hours  after 
the  transfusion  the  cyanosis  was  lessened,  the  body  temperature  rose  one 
degree,  and  this  improvement  continued  and  aided  the  general  nutrition. 
I  am,  therefore,  encouraged  to  believe  that  transfusion  should  be  added  to 
our  therapeutic  measures  in  marasmic  infants. 

It  is  a  great  pleasure  to  acknowledge  the  valuable  association  of  Dr. 
A.  Zingher  and  Dr.  Abrahams,  of  the  Eesearch  Laboratory,  and  the  co-op- 
eration of  the  Resident  Staff  of  Willard  Parker  Hospital,  in  furnishing 
clinical  assistance  and  bedside  notes. 


CHAPTER  X. 

VARICELLA    (CHICKEN-POX). 

Varicella  is  a  specific  infectious  disease  of  an  acute  character.  The 
eruption  consists  of  vesicles,  which  appear  in  successive  crops.  The  attack 
lasts  in  all  from  four  to  fourteen  days.  After  one  attack  the  child  is  usually 
immune  during  the  rest  of  its  life. 


Fig.  20L — Pustules  surrounded  by  an  inflammatory  areola.  From  the 
service  of  the  Willard  Parker  Hospital.  (Courtesy  of  Dr.  Howard 
Fox.) 

Etiolo^. — This  disease  is  seen  only  in  young  children;  the  older  the 
child,  the  less  liable  it  is  to  have  chicken-pox.  Nurslings  are  frequently 
afflicted. 

Hutchinson  states  that  in  his  experience  adults  are  almost  absolutely 
immune  from  this  disease.  In  my  own  practice  the  majority  of  cases  seen 
by  me  have  been  in  children  between  the  second  and  tenth  years  of  age. 

Pathology. — The  pathological  lesions  are  confined  wholly  to  the  epi- 
dermis. "The  vesicles  contain  granular  fibrin,  a  moderate  cellular  exudate, 
cellular  debris,  and  serum ;  this  differs  markedly  from  the  exudate  in  variola, 
which  is  usually  very  rich  in  cells,  especially  plasma  cells.  The  pock  in 
varicella  is  shallow,  rarely  involving  the  papillae  of  the  cutis,  and  as  its  con- 

(633) 


634  THE  INFECTIOUS  DISEASES. 

tents  are  absorbed,  the  superficial  covering  is  cast  off  in  the  form  of  a 
brownish  scab,  sometimes  with  marked  pigmentation,  but  no  resulting  scar. 
The  occurrence  of  a  scar  following  the  varicella  lesion  is  occasionally  seen." 
Diagnosis. — The  distinguishing  features  of  varicella  are:  "(a)  Its 
mild  prodromal  symptoms,  which  may  be  wholly  absent.  (&)  The  appear- 
ance of  the  eruption  on  the  trunk,  where  it  is  usually  more  abundant  than 
on  the  face  and  hands,  (c)  The  multiform  character  of  the  eruption,  its 
superficial  position,  comparable  to  drops  of  water  sprinkled  over  the  skin, 
and  its  appearance  on  the  same  region  in  successive  crops,  (d)  Its  mild 
constitutional  symptoms  and  short  duration ;  the  disease  usually  terminates 
within  from  five  to  fourteen  days,  (e)  Varicella  is  mildly  infectious  and 
always  gives  rise  to  a  like  disease." 

A  nursing  infant,  about  five  months  old,  refused  the  breast,  and  seemed  to 
show  a  general  malaise.  The  infant  had  previously  enjoyed  good  health.  The 
nursing  was  regularly  carried  out  and  the  bowels  were  normal.  The  temperature 
was  100°  F.  There  was  no  cough.  On  the  second  day  of  this  malaise  several 
vesicles  appeared  on  the  abdomen  and  back.  Later,  some  vesicles  appeared  on  the 
buttocks,  thighs,  and  in  the  roof  of  the  mouth.  There  was  no  constitutional  dis- 
turbance and  on  the  third  day  of  illness  the  infant  again  nursed  as  usual.  Several 
successive  crops  appeared,  and  each  eruption  remained  about  three  days.  Local 
treatment  consisted  in  dusting  the  parts  with  cornstarch.  Bathing  was  prohibited 
and  small  doses  of  calomel  were  given.    No  complications  followed. 

Differential  Diagnosis. — ^This  disease  may  be  confounded  with  variola, 
as  some  mild  cases  of  variola  resemble  chicken-pox.  "The  superficial  strata 
of  the  epidermis  are  principally  involved,  and  a  serous  exudate,  which  is 
frequently  the  first  sjnnptom  of  the  disease,  occurs  at  this  point,  resulting 
in  a  transparent,  thin-walled  vesicle,  while  in  variola  the  shot-like,  deep- 
seated  induration  and  subsequent  vesicular  formation  are  sufficiently  dis- 
tinctive to  warrant  a  differential  diagnosis.  The  lesions  in  varicella,  as  a 
consequence,  are  easily  destroyed,  and  when  seen  present  a  transparent, 
beady  appearance,  some  of  which,  having  ruptured,  leave  excoriated  areas ; 
whereas  in  variola  it  is  impossible  to  rupture  the  lesions  so  as  to  evacuate 
the  entire  contents  vtdthout  numerous  punctures  or  by  totally  destroying  the 
diseased  area." 

In  variola  we  have  more  uniformity  of  development :  first  papules  fol- 
lowed by  pustules  and  ending  iii  desiccation,  leaving  black  crusts.  In 
chicken-pox  we  find  a  varying  of  lesions  at  the  same  time,  so  that  we  may 
have  macules,  vesicles,  and  pustules  at  one  and  the  same  time.  In  variola 
the  eruption  is  thickly  seen  on  the  face  and  hands,  the  exposed  portions  of 
the  body.  In  chicken-pox  the  eruption  is  seen  on  the  abdomen  and  back; 
the  parts  protected  by  clothing  are  usually  first  covered.  When  called  to 
doubtful  cases  the  following  points  are  worth  noting: — 

Umbilication  is  seen  in  smallpox;  it  is  absent  in  chicken-pox.  "The 
length  of  time  since  vaccination,  and  whether  or  not  the  patient  has  ever 


VARICELLA. 


635 


had  chicken-pox.  Smallpox  is  extremely  seldom  encountered  within  three 
or  four  years  after  vaccination,  while  after  that  time  the  number  of  cases 
of  varioloid  or  abortive  smallpox  steadily  increase.  Chicken-pox,  like 
smallpox,  occurs  but  once  in  the  same  individual.  Prodromal  symptoms 
are  always  present  for  several  days,  usually  three,  in  variola;  absent  or  of 
a  few  hours'  duration  in  varicella. 

"The  temperature  often  renders  valuable  aid  in  differentiating  between 
the  two  diseases.  In  variola  it  rises  rapidly,  and  even  in  mild  or  abortive 
cases  usually  reaches  103°  to  104°  P.,  when,  on  the  appearance  of  the  rash, 
a  crisis  takes  place  and  it  falls  to  the  normal  within  a  few  hours,  where  it 
may  remain  throughout  the  remainder  of  the  disease.     Varicella,  on  the 


Bcite 

1 

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contrary,  is  seldom  ushered  in  with  fever,  but  the  temperature  usually  rises 
one  or  more  degrees  as  the  eruption  develops.  When  the  case  is  seen  for 
the  first  time  after  the  eruption  has  appeared  and,  as  often  occurs,  no  definite 
history  can  be  obtained,  other  symptoms  must  be  relied  upon,"    ■ 

Varicella  may  also  resemble  impetigo.  Impetigo  is  first  seen  on  the 
face,  especially  about  the  mouth  and  nose.  It  is  also  seen  on  the  hands. 
In  studying  the  regional  appearance  of  the  eruption  one  can  readily  see 
the  transmission  and  inoculation  from  face  to  hands  and  vice  versa.  This 
condition  is  never  met  with  in  chicken-pox.  Impetigo  may  last  weeks  and 
months.  Chicken-pox  rarely  exists  more  than  two  weeks.  Impetigo  is 
contagious  and  not  infectious.  Chicken-pox  has  been  successfully  inocu- 
lated. 

Progptiosis. — The  prognosis  is  invariably  good.  I  have  never  heard  of 
a  fatal  case  of  chicken-pox.  Complications  should,  however,  be  guarded 
against  and  not  invited  by  carelessness. 


636 


THE  INFECTIOUS  DISEASES. 


Treatment. — A  child  suffering  with  chicken-pox  should  be  put  to  bed 
and  strictly  isolated.  Healthy  children  should  not  come  into  contact  with 
a  case  of  chicken-pox  for  at  least  two  weeks. 

The  diet  should  be  liquid,  and  feeding  should  be  given  at  regular 
intervals.  The  bowels  should  be  loose,  and  if  necessarj^  stimulated  by  the 
aid  of  a  laxative. 

For  the  eruption  flannels  and  woolens  should  be  avoided,  and  a  cool, 
loosely  fitting  linen  or  muslin  shirt  or  go"«Ti  should  be  worn.     It  is  safe  to 


1. 

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Fig.  203. — Erysipelas  Following  Varicella.  Locally,  pure  alcohol  in 
which  1 :  2000  bichloride  mercury  was  dissoh'ed  Avas  applied  on  the  erysipela- 
tous surface  continually.     Case  recovered.      (Original.) 


proliibit  the  daily  bath  until  the  eruption  has  disappeared.  I .  prefer  to 
dust  the  skin  with  some  bland  dusting  powder,  such  as  talcum,  cornstarch, 
or  rice  powder,  several  times  a  day.  Iron  and  tonics  may  be  given  later  if 
required.  Locally,  a  paste  made  by  mixing  bicarbonate  of  soda  with  cold 
water  and  applied  to  the  chicken-pox  is  cooling. 

Baby  B.,  five  months  old,  was  attended  by  me  in  January,  1905.  The  infant 
had  a  severe  form  of  varicella  with  gastric  disturbances,  such  as  vomiting  and 
diarrhea.  On  the  sixth  day  after  the  apix'arance  of  the  chicken-pox  the  infant 
gcj-atched  its  ^rm,     On  the  following  day  there  was  a  temperature  of  102°  and  a 


VAMCELLA.  637 

diiruse  swc'lli]!^,'  surrounded  the  upper  arm.  There  was  marked  tenderness  and  pain 
on  the  slightest  motion.  The  swelling  increased.  The  arm  became  reddened  and  a 
diffuse  erysipelas  was  diagnosed.     The  temperature  increased  to  105.8°. 

Treatment. — Local  treatment  consisting  of  evaporating  cooling  lotions;  lead 
and  opium  wash  and  bicliloride  were  used  without  any  marked  benefit.  Crede 
ointment  was  rubbed  into  tlie  axillary  glands  several  times  a  day.  An  injection  of 
10  cubic  centimeters  of  antistreptococcus  serum  (Aronson)  seemed  to  have  very 
good  effect.  The  cooling  lotions  were  continued,  but  within  twenty-four  hours  after 
the  serum  injection  the  temperature  came  down  by  lysis  and  after  four  days  the 
temperature  was  normal.     The  case  recovered. 


CHAPTER  XI. 
VARIOLA  (SMALLPOX). 

This  acute  infectious  and  contagious  disease  is  frequently  seen  in  un- 
vaccinated  children.  It  is  rarely  met  with  in  children  that  have  been  prop- 
erly vaccinated.  I  have  seen  smallpox  in  very  young  infants  and  children 
that  wer-e  unvaccinated  during  my  service  at  the  Riverside  Hospital  in  the 
summer  of  1902. 


Fig.  204. — Two  children  in  the  Municipal  Hospital  of  Philadelphia,  one 
unvaccinated,  and  the  other  vaccinated  on  day  of  admission;  the  crust  still 
visible  on  the  leg.  This  child  remained  in  the  hospital,  with  its  mother 
who  was  suffering  from  smallpox,  for  three  weeks,  and  was  discharged  per- 
fectly well.  The  unvaccinated  child,  admitted  with  smallpox,  died.  (From 
"Acute  Contagious  Diseases,"  Welch  &  Schamberg.) 

Etiology. — The  etiological  factor,  most  likely  a  specific  micro-organ- 
ism, has  not  yet  been  found. 

Among  unvaccinated  children  between  1  and  10  years  of  age,  some 
authors  state  that  58  per  cent.  die.  During  the  Sheffield  epidemic,  of 
2892   unvaccinated   children   under   10   years   of   age  living   in   infected 

(638) 


VARIOLA, 


039 


houses,  7.8  per  cent,  were  attacked.  JJuring  the  Warrington  epidemic  54.5 
per  cent,  of  unvaccinated  children  under  10  years  of  age  were  attacked. 

It  is  a  curious  fact  that  the  resistance  of  chihlren  is  less  than  that  of 
adults.  Nursing  infants  frequently  have  mouth,  nose,  and  throat  com- 
plications, which  seriously  interfere  with  their  feeding,  causing  death. 

There  are  three  types  of  variola: — 


Taiu.k  No.  no. 


1.  Natural 


2.   Haemorrliagic 


3.  Modified. 


Discrete 
Confluent 

Semi-confluent 

Purpuric 

Hsemorrhagio 

Exudative 

(Anomalous 
Corymbose 


<  Discrete  when  the  erui>t:on  is  scattere;! 

i  Confluent   when   the   eru;)tiou     s   thick    and 
\         flows  together. 

/  Semi-conflaent  when  the  eruption  is  discrete 
\         in  some  parts  and  confluent  in  others. 


Corymbose  when   the    eruption  forms  groups 
or  clusters  on  various     arts  of  Ihe  body. 


T]ie  mode  of  infection  is  most  probably  a  micro-organism  which  exists 
either  in  the  vesicles,  pustules,  or  crusts.  It  may  be  carried  in  the  air  so 
that  infection  may  take  place  at  some  distance  from  the  body.  Some  au- 
thors believe  that  the  blood  of  smallpox  patients  contains  the  poison.  Small- 
pox can  be  transmitted  directly  from  person  to  person.  It  can  also  be  trans- 
mitted from  bedding  or  clothing  worn  by  an  infected  person.  Entering  a 
room  during  the  pustular  and  desquamative  stages  is  sufficient  to  commu- 
nicate the  disease. 

Symptoms. — In  young  children  the  disease  is  usually  ushered  in  with 
convulsions.  The  pulse-rate  ranges  between  130  and  IGO.  The  respira- 
tion is  labored  and  increased  in  frequency. 

Curschmann  believes  that  these  symptoms  are  due  to  an  irritation  of 
the  respiratory  centers. 

The  temperature  rises  rapidly  and  continuously  without  the  morning 
remission.  Beginning  with  102°  or  103°  F.  on  the  first  day  of  illness,  the 
temperature  soon  reaches  105°  F.  (40.5°  C.)  until  the  eruption  appears. 

With  the  first  appearance  of  the  eruption,  the  temperature  frequently 
drops  to  normal.  This  symptom  of  fever  occurs  in  no  other  exanthematous 
eruption. 

The  Eruption. — "Eeddish  specks  or  dots  developed  into  papules  re- 
sembling flea-bites  appear  about  the  second  day.     After  the  papules  have 


640 


THE  INFECTIOUS  DISEASES. 


attained  the  size  of  a  small  pea  their  summits  gradually  assume  a  trans- 
lucent glazed  appearance  which  indicates  the  formation  of  a  vesicle.  As 
this  enlarges  a  central  depression  or  umbilication  takes  place  which  is 
looked  upon  as  characteristic  of  the  smallpox  lesion.  If  punctured  a  small 
amount  of  mucilaginous  serum  exudes.  The  eruption  is  not  confined  to 
the  skin,  but  is  met  with  in  the  mucous  membrane  on  the  mouth,  throat, 
and  nose. 


Bate   2     3    4    5     6    7 

8     9     10    11    12 

J;^    MEMEMEMEMEME 

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jyiiEMEMEMEMEME 

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Fig.   205. — ^Temperature  Curve  in  Variola.      (Original.) 


Stage  of  Suppuration. — On  the  sixth  day  of  the  eruption  there  is  a 
decided  yellowish  tint,  due  to  the  presence  of  pus  cells  or  polymorphonuclear 
leucocytes  resembling  cream.  The  face  usually  presents  an  erysipfelatous 
redness. 

Stage  of  Decline. — About  the  twelfth  day  of  the  eruption  there  is  a 
spontaneous  rupture  of  the  pustules.  After  the  contents  are  thus  evacu- 
ated, or  by  absorption,  we  see  evidences  of  desiccation.  The  pustular  con- 
tents dry  up  and  the  pustule  dies,  leaving  a  blackish  crust.  These  blackish 
or  brownish"  crusts  appear  first  where  the  eruption  took  place.  We  there- 
fore first  note  this  condition  on  the  arms,  palms,  and  soles.  The  crusts 
separate  from  the  body  between  the  sixteenth  and  twenty-first  days. 

Desquamation  of  a  furfuraceous  character  takes  place,  lasting  from 


VARIOLA. 


nu 


one  to  two  weeks.  After  this  condition  has  disappeared  the  patient  may 
be  regarded  as  cured. 

Differential  Diagnosis.  —  Corlett  describes  the  great  resemblance  of 
smallpox  to  typhoid  i'ever  in  its  early  stages,  in  a  case  seen  by  him.  A 
strong  Widal  reaction  was  found,  besides  a  bronchitis. 

Measles  frequently  resembles  smallpox.  Catarrhal  symptoms  always 
present  in  measles  are  absent  in  smallpox.      The  lesions  in  measles  are 


Fig.  206— Smallpox  in  a  Child  that  was  Vaccinated  During  the 
Incubation  Period.  Vaccination  performed  five  days  before  the  appearance 
of  the  variolous  eruption.  Little  or  no  modification.  (Kindness  of  Dr. 
J.  F.  Sehamberg.) 

flat,  soft,  and  velvety  to  the  touch.  The  papnles  of  smallpox  are  small 
and  feel  like  shot  imbedded  in  the  skin. 

Scarlet  fever  sometimes  resembles  variola  of  a  mild  form.  The 
premonitory  symptoms  of  variola  are  very  severe,  and  last  two  or  three 
days,  whereas  those  of  scarlet  fever  are  mild,  last  a  few  hours,  and  not  in- 
frequently are  entirely  overlooked.  The  rash  in  scarlet  fever  appears  on 
the  upper  part  of  the  body,  chest,  cheeks,  and  neck.  In  variola  a  scar- 
latinal form  of  eruption  is  seen  on  the  lower  part  of  the  abdomen  and  on 
the  inner  surface  of  the  thighs.  It  is  bright  and  fiery  red  m  scarlet  fever 
and  dull  red  in  variola.  The  conspicuous  papillae  or  strawberry  tongue  is 
present  in  scarlet  fever  and  absent  in  smallpox. 

Impetigo  is  frequently  mistaken  for  smallpox.  Corlett  describes  the 
presence  of  supposed  impetigo  in  Ohio  in  1898  which  gave  rise  later  on 


642  TT-IE  INFECTIOUS  DISEASES. 

to  an  epidemic  oi  smallpox.  Thus  it  is  apparent  that  there  is  a  great 
resemblance  between  impetigo  and   smallpox,  and  vice  versa. 

Chicken-pox  is  frequently  mistaken  for  smallpox.  I  have  already  out- 
lined the  differential  points  in  describing  chicken-pox  (see  chapter  on 
"Varicella"). 

Syphilis  may  sometimes  be  mistaken  for  variola.  A  study  of  the 
temperature  and  pulse  and  careful  observation  for  several  days  will 
usually  clear  up  the  diagnosis.  In  variola  the  eruption  assumes  a  pus- 
tular character  on  the  palms  and  soles. 

The  Prognosis  and  Course  are  always  bad  in  unvaccinated  children,  es- 
pecially in  the  very  young.     In  the  vaccinated  the  prognosis  is  always  good. 

A  series  of  cases  was  seen  by  me,  during  the  summer  of  1902,  in  the 
smallpox  wards  of  the  North  Brothers'  Island  Hospital.  Out  of  twelve 
children  seen  not  one  had  been  vaccinated.  One  child  was  infected  by 
its  mother. 

As  a  rule  the  course  extends  over  three  weeks,  rarely  lasting  four  weeks. 
Complications  of  the  nose,  mouth,  and  throat  of  a  catarrhal  nature  are 
occasionally  seen.  The  outcome  of  the  cases  seen  by  me  was  quite  good 
in  spite  of  the  severe  character  of  the  disease. 

Complications. — Swelling  of  the  mucous  membrane,  such  as  oedema  of 
the  glottis,  bronchitis,  and  broncho-pneumonia,  frequently  complicates 
variola.  The  eruption  plus  secretion,  when  present  in  the  throat,  are  the 
cause  of  great  irritation,  and  give  rise  to  a  hacking  cough.  Suffocatory 
symptoms  may  follow  oedema  of  the  glottis.  Otitis  of  a  purulent  nature 
is  frequently  seen.    It  is  usually  accompanied  by  severe  neuralgic  pains. 

Treatment. — The  best  sanitary  surroundings,  fresh  air,  and  the  strict- 
est possible  isolation  are  advisable.  The  local  application  of  a  solution  of 
glycerine  and  carbolic  acid  will  tend  to  relieve  the  itching,  and  to  soften  the 
crusts. 

The  bowels  should  be  kept  thoroughly  cleansed,  and  the  patient  made 
comfortable  by  a  tepid  pack  if  the  temperature  is  high  or  if  delirium  is 
j)resent.  An  ice-cap  and  cold  colon  flushing  will  render  the  patient  more 
comfortable.  If  cardiac  depression  exists,  stimulation  with  musk,  cam- 
phor, or  champagne  is  advisable.  Eegarding  sanitary  measures  the  New 
York  Health  Department  requires  the  immediate  removal  of  a  case  of  this 
kind  to  the  smallpox  hospital.  The  disinfection  and  thorough  fumiga- 
tion of  everything  which  was  in  contact  with  the  case  must  be  remem- 
bered if  we  wish  to  prevent  the  spread  of  the  disease. 

Vakioloid    (Modified  Smallpox). 

The  symptoms  are  milder,  the  papules  less  in  number,  and  the  gen- 
eral condition  shows  an  infection  of  a  lesser  type  than  we  see  in  variola. 


Variola. 


643 


,     Fig.    207 — Mild    Discrete    8niiillpox    in    mi    riivat'einateil    Girl.     Note 
absence   of   lesions    upon    the    trunk.  (Kindness    of    Dr.    J.    F.    Scham- 

berg.) 


644  THE  INFECTIOUS  DISEASES. 

The  febrile  symptoms  may  be  the  same  as  we  see  in  true  smallpox.  The 
attack  is  shorter.  The  severity  of  the  symptoms  depends  on  the  length  of 
time  since  the  last  vaccination  took  place. 

Vaccination  (Vaccinia). 

This  disease  can  be  induced  by  inoculating  the  arm  or  leg  with  bovine 
or  human  virus.  By  inducing  this  disease  we  protect  against  smallpox. 
The  serum  employed  is  usually  taken  from  a  calf  suffering  with  vaccinia  or 
cow-pox.  By  inoculating  the  body  with  this  cow-pox  we  produce  kn.  im- 
munity which  protects  against  smallpox.  During  my  service  at  the'^Eiver- 
side  Hospital;,  I  have  frequently  seen  infants  that  had  never  been  vaccinated 
suffering  with  smallpox.  I  have  never  seen  a  case  of  smallpox;^  an  infant 
previously  vaccinated. 

When  we  consider  the  ease  with  which  we  can  confer  immunity  and 
protect  the  human  body  against  smallpox,  then,  it  seems  nothing  less  than 
criminal  to  permit  an  innocent  human  being  to  go  about  unvaccinated. 

Symptoms. — From  five  to  ten  days  after  inoculation  a  red  areola  is 
seen  around  the  wound.  Inflammatory  symptoms  are  marked.'  The 
neighboring  lymph  glands  are  swollen.  An  eruption  resembling  measles  or 
scarlet  fever  sometimes  follows  vaccination.  ^ 

It  usually  involves  the  arms,  neck,  and  chest;  in  rare  cases  it  involves 
the  whole  body.  It  most  commonly  occurs  between  the  eighth  and  eleventh 
days  after  vaccination.  The  temperature  is  rarely  above  normal  and  there 
is  no  constitutional  disturbance. 

The  Complications. — ^Eare  complications  are  erysipelas  and  cellulitis. 
Abscesses  are  usually  the  result  of  carelessness  or  iafection.  This  infection 
usually  takes  place  at  the  time  of  inoculation  or  may  result  from  dirt  or 
scratching  with   dirty  nails,   or  other  filthy   habits.      (Read   chapter   on 

"Varicella.'^ 

Syphilis  and  tuberculosis  are  mentioned  as  accidental  infections,  but  I 
have  never  seen  or  heard  of  a  hona  fide  case  resulting  from  vaccination. 

Varieties  of  Vaccine. —  (a)  Humanized.  ,  (&)  Bovine.  Humanized  vac- 
cine is  rarely  or  never  used.  By  using  hum^n  virus  the  chance  of  conveying 
S3rphilis  or  other  disease  ha^  been  thought  possible.  Therefore,  the  bovine 
virus  has  been  given  preference. 

Where  to  Inoculate. — Usually  on  the  arm,  although  the  leg  is  some- 
times preferred  for  females.  The  upper  third  of  the  arm  is  the  part  usually 
chosen.  When  preference  is  shown  for  vaccination  on  the  leg  in  female 
infants,  the  lower  anterior  outer  third  should  be  chosen.  Good  vaccine 
virus  will  take  on  almost  any  part  of  the  body. 

Method  of  Inoculation. — The  parts  to  be  inoculated  should  be  cleaned 
with  soap  and  water;  also  the  operator's  hands.  After  thorough  drying  of 
the  parts  with  cotton,  a  sterile  needle  should  be  used  for  scarification.    A 


PI.ATK   XXX 


Conlhii'iit  Type  of  Smallpox.     Seventh  day  of  vaccination.     Vaccinat^-d  too 
late — (hiring  incubation  period.      (Courtesy  of  Dr.  Schaniberg.) 


VACCINIA.  645 

small  area  of  epidermis  should  be  removed,  but  no  blood  should  be  drawn. 
No  antiseptic  should  be  used  to  clean  the  part  to  be  inoculated;  otherwise, 
we  destroy  the  vaccine  virus. 

Welch  and  Schambcrg/  in  a  series  of  cases,  call  particular  attention  to 
the  great  difference  in  the  death-rate  between  the  vaccinated  and  the  un- 
vaccinated  patients.  Those  who  were  vaccinated  in  infancy  and  showed 
good  scars  gave  the  remarkably  low  death-rate  of  2.61  per  cent.,  as  against 
the  high  death-rate  of  28.17'  per  cent,  in  the  unvaccinated.  There  is  no 
doubt  that  all  those  who  showed  either  good  or  fair  scars  were  successfully 
vaccinated.     If  we  consider  them  together,  the  death-rate  is  4.84  per  cent. 

In  making  a  comparison  between  the  vaccinated  and  unvaccinated 
cases,  it  is  scarcely  fair  to  include  vaccinated,  all  the  cases  showing  poor 
scars,  as  very  many  of  them,  doubtless,  were  never  successfully  vaccinated. 

Patients  who  had  been  vaccinated  seven  days,  or  less  than  seven  days, 
before  the  appearance  of  the  eruption  of  small-pox  gave  a  death-rate  of 
35.71  per  cent.,  while  those  who  had.  been  vaccinated  for  a  longer  period 
than  seven  days  before  the  outbreak  of  the  efflorescence  gave  a  death-rate 
of  only  14.28  per  cent. 

Treatment. — The  vaccinated  area  should  be  covered  with  a  square  piece 
of  sterilized  gauze  held  in  place  with  strips  of  adhesive  plaster.  This  dress- 
ing should  not  be  removed  for  one  week.  In  some  cases  a  shield  or  protector 
containing  a  piece  of  gauze  will  keep  the  inoculated  area  clean  and  dry  and 
the  clothing  from  adhering.  The  rules  of  asepsis  are  very  important  in 
vaccination.  If  the  skin  is  thoroughly  scrubbed,  so  that  no  bacteria  remain, 
then  an  infection  will  probably  be  ruled  out.  If,  on  the  other  hand,  asepsis 
was  not  carried  out,  then  vaccinal  ulcers  will  result. 

Local  treatment  consists  in  saturating  the  gauze  with  antistreptococcus 
serum  several  times  a  day.  To  retain  the  moisture  of  the  serum,  the 
gauze  is  covered  with  oiled  silk.  Sexton-  reports  very  successful  results 
from  this  treatment. 

Vaccinia. 

This  acute  condition  is  characterized  by  an  eruption  following  the 
inoculation  of  lymph.  When  lymph  is  taken  from  a  seropurulent  eruption 
on  the  teat  or  udder  of  a  cow,  it  is  called  cow-pox.  Some  authors  believe 
that  vaccinia  is  a  modified  form  of  smallpox. 

Symptoms. — An  eruption  resembling  measles  or  scarlet  fever  sometimes 
follows  vaccination.  It  usually  involves  the  arms,  neck,  and  chest;  in  rare 
cases  it  involves  the  whole  body.  It  most  commonly  occurs  between  the 
eighth  and  eleventh  days  after  vaccination.  The  temperature  is  rarely 
above  normal  and  there  is  no  constitutional  disturbance.  There  is  no  treat- 
ment excepting  cleanliness.    Internally,  a  mild  laxative  may  be  given. 


1  Therapeutic  Gazette,  June  15,  1902. 
'Archives  of  Pediatrics,  Feb.,  1913. 


CHAPTEE   XII. 

TYPHOID  FEVER. 

Typhoid  fever  is  an  acute  infectious  disease  caused  by  the  invasion  of 
a  specific  micro-organism,  known  as  Eberth's  typhoid  bacillus. 

Etiology. — ^Typhoid  is  rarely  seen  in  infants.  It  is  most  frequently 
seen  in  children  over  5  years  of  age.  In  a  series  of  97  cases  described  by 
Henoch : — 

2  eases  occurred  during  the  1st  year 
21  cases  between  the  2d  and  5th  years 
59  cases  between  the  5th  and  10th  years 

Von  Steffens  in  a  series  of  148  cases  reports : — 

2  cases  occurred  during  the  1st  year 
28  cases  between  the  3d  and  6th  years 
34  cases  between  the  6th  and  9th  years 

I  have  seen  typhoid  fever  in  an  infant  1  year  old  which  was  infected 
by  its  mother. 

Baginsky  describes  an  epidemic  of  typhoid  seen  by  him  in  Germany 
in  which  16  cases  were  under  10  years  of  age. 

Infected  water  and  infected  milk  appear  to  have  caused  this  disease 
more  than  any  other  factor,  Baginsky  mentions  flies  as  an  occasional 
source  of  infection. 

The  New  York  Health  Department,  in  a  circular  of  information  con- 
cerning the  urine  in  typhoid  fever,  directs  attention  to  the  fact  that  "the 
typhoid  bacilli  are  present  in  almost  incredible  numbers,  estimated  at  many 
millions  per  cubic  centimeter." 

These  germs  find  a  suitable  culture  medium  for  their  propagation  in 
the  intestinal  tract.  They  are  very  easily  found  in  the  faeces  in  the  living 
state  during  the  height  of  the  disease. 

The  entrance  of  the  typhoid  bacillus  into  the  gastro-intestinal  tract, 
whether  it  is  in  food,  liquid  or  solid,  is  responsible  for  the  disease.  It  is 
true  that  a  receptive  condition  may  exist.  A  child  having  had  a  series  of 
gastro-intestinal  attacks  is  more  liable  to  an  infection  than  one  whose  diges- 
tive tract  is  normal.  Eickets  and  a  general  debilitated  condition  certainly 
favor  the  development  of  typhoid. 

Typhoid  fever  occurs  most  frequently  in  the  fall  of  the  year.  I  have 
seen  more  cases  of  typhoid  in  children  during  September  and  October  than 
during  the  rest  of  the  year.  During  the  fall  and  winter  of  1902  and  1903 
some  of  the  worst  cases  of  typhoid  with  haemorrhages  occurred. 

Bacteriology. — ^The  typhoid  bacillus  resembles  the  bacillus  coli  com- 
munis, and  is  found  chiefly  in  the  lymphoid  tissue  of  the  small  intestines, 
especially  in  .Peyer's  patches,  where  it  produces  a  specific  inflammation. 
The  bacillus  is  found  not  only  within  the  intestines,  but  in  the  glands  as 
well.  Neuhaus  found  the  bacillus  by  puncturing  the  roseolar  eruption 
and  examining  the  blood  therein.  It  has  also  been  found  in  laryngeal 
(646) 


TVPIIOID    FP]VER. 


047 


ulcerations  during  typhoid.     The  bacillus  was  also  found  in  the  purulent 

meningitis  accompanying  typhoid,  so  that  we  can  be  reasonably  certain 

that  the  bacillus  abounds  in  almost  every  part  of  the  body.      The  action 

of  typhoid  bacillus  on  the  human  system  is 

toxic.     Brieger  isolated  a  poison  from  the 

typhoid  bacillus,  which  is  called  the  typlio- 

toxin. 

Pathology. — The  pathological  findings 
consist  in  an  inflammatory  condition  of  the 
mesenteric  glands ;  besides  these  the  solitary 
and  agminated  glands  of  the  ileum  and  colon 
liot  only  show  evidences  of  swelling,  but 
when  the  disease  pfogreg^es  it  frequently  ter- 
minates in  ulceration  ^nd  necfosig. 

Occasionally  the  glands  will  show  a 
softening  and  pus  will  develop.  The  spleen 
is  usually  very  large  and  soft,  and  quite  pal- 
pable. When  the  disease  lasts  several  weeks 
and  there  are  evidences  of  a  distinct  toxgemia, 
the  poison  will  cause  a  marked  degeneration 
of  the  kidneys  and  liver,  also  affecting  the 
heart  muscles,  which,  later,  will  be  found 
very  soft  and  flabby. 

Morse^  reports  several  cases  of  fatal  and 
infantile  typhoid. 

Fecial  and  Infantile  Typhoid. — In  re- 
gard to  foetal  typhoid  he  says  that  the  ty- 
phoid bacillus  can  transverse  the  abnonnal, 
and  possibly  the  normal  placenta  from 
mother  to  foetus.  Other  organisms  may  also 
pass  in  the  same  way. 

Infection  of  the  fretus  results.  Because 
of  the  direct  entrance  of  the  bacilli  into  the 
circulation,  intrauterine  typhoid  is  from  the 
first  a  general  septicaemia.  For  this  reason, 
and  possibly  also  because  the  intestines  are 
not  functionating,  the  classical  lesions  of 
intrauterine  typhoid  are  wanting. 

The  fcrtus  usually  dies  in  utero  or  at  birth  as  the  result  of  the  typhoid 
infection. 

It  may  be  born  alive  but  feeble  and  suffering  from  the  infection.     It 
SO,  death  occurs  in  a  few  days  without  definite  symptoms, 

^Archives  of  Pediatrics  fpr  December,  1900. 


Yiff.  20S. — Typhoid  Infantum 
in  a  2-Year-Old  Boy.  (a)  Soli- 
tary follicle;  (b)  small  agmin- 
ated gland;  (c)  Peyer's  patch. 
General  medullary  infiltration, 
no  ulceration.  Natural  size. 
(Langerhans.) 


648  THE  INFECTIOUS  DISEASES. 

It  is  possible  that  the  foetus  may  pass  through  the  infection  in  utero 
and  be  born  alive  and  well.    There  is,  however,  no  proof  that  this  happens. 

Infection  does  not  always  occur.  The  pregnant  woman  does  not  neces- 
sarily transmit  the  disease  to  her  child. 

As  to  infantile  typhoid  Morse  concludes  that  except  for  the  lessened 
exposure  in  the  first  year  through  food  there  seems  no  obvious  reason  why 
typhoid  should  be  less  frequent  in  infancy  than  in  later  life.  Nevertheless, 
judging  from  the  small  number  of  cases  reported,  it  is  less  frequent.  It  may 
really  be  less  frequent,  or  only  apparently  so  because  the  disease  is  not  recog- 
nized, being  mistaken  for  other  conditions.  Bacteriological  examinations  in 
large  series  of  autopsies  on  infants  and  the  use  of  the  Widal  serum  test  in 
large  numbers  of  sick  babies  seem  to  offer  the  best  means  for  determining 
both  the  frequency  and  the  character  of  the  disease  at  this  age. 

The  accuracy  of  the  diagnosis  in  many  of  the  earlier  reported  cases 
must  be  regarded  as  very  doubtful,  and  hence  no  satisfactory  conclusions 
can  be  drawn  from  them.  Analysis  of  the  more  recent  and  certain  cases 
seems  to  show  that  the  symptoms  of  infantile  typhoid  are  essentially  the 
same  as  in  adults,  but  that  the  course  is  shorter  and  the  mortality  greater. 
These  conclusions  may  be  inaccurate,  however,  as  it  is  possible  that  they 
are  based  on  the  severe  cases  alone,  the  milder  cases  having  escaped  notice. 
The  pathological  changes  in  the  intestines  are,  as  a  rule,  insignificant.  The 
contrast  between  them  and  the  severity  of  the  general  symptoms  is  striking. 
The  probable  explanation  is  that  in  the  infant  as  in  the  foetus,  but  to  a  less 
degree,  the  disease  is  a  general  rather  than  a  local  infection. 

The  serum  reaction  occurs  in  infantile  as  in  adult  typhoid.  There  are 
no  data  as  to  whether  or  not  it  occurs  in  foetal  typhoid. 

Immunity. — The  agglutinating  power  may  or  may  not  be  present  in 
the  blood  of  infants  born  of  a  woman  with  typhoid.  If  present,  it  is  trans- 
mitted from  the  mother  to  the  child  through  the  placenta.  It  is  possible, 
however,  that  it  may  be  formed  in  the  child  in  response  to  toxins  trans- 
mitted through  the  placenta.  The  agglutinating  principle  can  pass  through 
the  normal  placenta.  Part  of  it,  however,  is  arrested  in  the  passage. 
Whether  or  not  it  is  transmitted  seems  to  depend  on  the  strength  of  the 
agglutinating  power  in  the  maternal  blood  and  the  length  of  time  during 
which  the  placenta  is  exposed  to  it. 

It  may  be  transmitted  to  the  nursling  through  the  milk.  It  may  appear 
in  the  infant's  blood  in  less  than  twenty-four  hours.  It  lasts  but  a  few 
days  after  the  cessation  of  nursing.  It  is  always  weaker  in  the  milk  than 
in  the  maternal  blood  and  always  weaker  in  the  infant's  blood  than  in  the 
milk.  This  weakening  of  the  agglutinating  power  is  due  to  the  obstruction 
to  its  passage  in  the  mammary  gland  and  in  the  nursling's  digestive  tract. 
The  chief  factor  governing  transmission  is  the  intensity  of  the  power  in 
the  maternal  blood.    A  subordinate  but  important  factor  is  some  unknown 


TYPHOID    FEVER.  549 

condition  in  the  digestive  tract.  If  the  power  in  the  maternal  blood  is 
weak  and  the  obstacles  great  it  may  not  be  transmitted. 

Symptoms. — The  symptoms  are  usually  very  obscure  in  children. 
Vomiting  and  sometimes  diarrhoea  are  the  earliest  symptoms.  In  other 
cases  constipation  may  be  an  early  symptom.  The  so-called  pea-sdup  diar- 
rhoea seen  in  adults  and  older  children  is  rarely  met  with  in  young  infants. 
Convulsions  frequently  usher  in  an  attack  of  typhoid  fever. 

In  older  children,  those  able  to  complain  will  usually  give  subjective 
symptoms,  which  may  aid  materially  in  making  the  diagnosis.  A  constant 
headache,  for  example,  will  always  show  a  severe  form  of  infection,  and 
may  bo  the  only  symptom  which  will  be  constant. 

The  period  of  incubation  varies  from  five  to  fourteen  days.  We  can 
safely  say  it  is  rare  for  the  period  of  incubation  to  extend  over  three  weeks. 

TJie  Temperature. — The  temperature  is  one  of  the  mam  indications 
of  typhoid.  It  rises  at  night  and  falls  in  the  morning,  the  morning  fall 
being  less  and  the  evening  rise  greater  for  the  first  week  (step-laddder  type) 
until  the  maximum  is  reached.  The  temperature  shows  fairly  regular  oscil- 
lations, morning  fall  and  evening  rise  for  about  a  week.  It  then  returns 
to  normal  at  the  end  of  the  third,  sometimes  at  the  end  of  the  fourth  or  fifth 
week.     The  temperature  drops  by  lysis,  never  by  crisis. 

Secondary  fever  is  rare  in  children.  It  is  not  unusual  to  find  a  mild 
form  of  typhoid  terminating  normally  at  the  end  of  two  weeks. 

During  the  second  week  of  the  disease  when  the  temperature  remains 
fairly  constant,  the  diagnosis  will  be  much  easier,  although  a  positive  diag- 
nosis from  the  temperature  alone  should  not  be  made.  The  temperature  in 
a  mild  form  of  typhoid  in  an  infant  varies  between  101°  and  103°  F.  during 
the  first  week,  or  even  the  second  week,  of  the  disease.  Severe  cases  may 
show  a  temperature  of  105°  F.,  or  even  higher,  during  the  first  week  of 
the  illness.  The  temperature  may  show  peculiar  variations.  We  may  have 
a  sudden  rise  extending  over  a  period  of  six  weeks  instead  of  three  weeks. 
This  prolonged  pyrexia  sometimes  denotes  complications.  If  the  tempera- 
ture has  ranged  between  103°,  104°,  or  105°  F.,  and  suddenly  drops  to 
normal  or  subnormal,  then  we  must  suspect  either  an  internal  ha3morrhage 
or  look  for  a  perforation.  Sudden  variations  in  the  temperature,  as  a  very 
sudden  rise  or  fall,  must  always  be  looked  upon  with  suspicion.  There  is 
no  crisis  in  typhoid  as  there  is  in  pneumonia. 

The  Pulse. — The  pulse  is  usually  increased  in  frequency  and  ranges 
between  130  and  160  per  minute.  The  force  and  rhythm  are  good  unless 
some  complication  arises.  The  pulse  is  usually  small  and  compressible,  and 
there  is  very  low  tension  in  fatal  forms  of  the  disease. 

The  Tongue. — The  tongl^e  is  coated  with  a  whitish,  more  rarely  a 
brownish,  fur.    This  coating  extends  down  the  center,  although  the  whole 


650 


THE  INFECTIOUS  DISEASES. 


tongue  may  be  covered.  The  mouth,  appears  very  dry,  and  the  patient 
sometimes  complains  of  intense  thirst. 

The  abdomen  is  usually  distended  with  gas  and  there  m  marked  tym* 
panites  on  percussion.  Gurgling  and  tenderness  on  palpation  in  the  ileo- 
CEecal  region  is  not  to  be  looked  upon  as  an  important  symptom. 

The  Spleen. — The  spleen  cannot  be  relied  upon  as  a  diagnostic  aid  in 
children.  While  it  may  be  enlarged  in  some  instances,  we  frequently  find 
that  it  is  not  palpable  in  many  cases  of  severe  typhoid. 

Coughs  and  Bronchial  Catarrh. — One  of  the  earliest  symptoms  in  ty- 
phoid is  bronchitis.  In  the  beginning  when  we  have  but  cough  and  fever 
the  diagnosis  will  be  quite  difficult.     Typhoid  frequently  simulates  pneu- 

The  Nervous  System. — In  profound  tox- 
icity the  nervous  symptoms  present  will  be 
muttering,  delirium,  and  a  semi-comatose 
condition.  Not  infrequently  rigidity  of  the 
muscles  of  the  neck  is  present,  so  that  the 
difi;erential  diagnosis  from  meningitis  will 
be  difficult.  The  nervous  symptoms  fre- 
quently resemble  those  seen  in  tubercular 
meningitis.  Acute  tuberculosis  may  some- 
times resemble  typhoid. 

Extreme  Emaciation.  —  Children  fre- 
quently show  emaciation  during  typhoid  for 
the  following  reasons : — 

1.  The  constant  fever. 

2.  The  low  vitality  owing  to  mal- 
nutrition. 

3.  The  system  being   constantly   drained  when   diarrhoea  exists. 

Diagnosis. — In  every  case  of  fever  in  which  a  diagnosis  cannot  be  made, 
a. drop  of  blood  should  be  examined  for  the  presence  of  the  Widal  reaction. 
This  reaction  is  always  a  trustworthy  evidence  of  the  presence  of  typhoid, 
and  a  negative  reaction  later  than  the  tenth  day  is  strong  but  not  absolutely 
convincing  evidence  of  the  absence  of  typhoid.  The  test  is  of  greater 
value  in  the  case  of  an  infant  than  an  adult,  as  we  can  exclude  the  occurrence 
of  a  previous  attack.  Some  writers  state  that  the  reaction  is  seen  earlier 
in  children  than  in  adults. 

It  should  not,  however,  be  the  only  means  of  making  a  diagnosis.  It 
is  well  known  that  this  reaction  will  occur  months  and  sometimes  years 
after  the  patient  has  recovered  from  typhoid,  hence  great  caution  should  be 
used  in  relyiDg  on  this  diagnostic  measure  exclusively. 

Widal  Test  for  the  Diagnosis  of  Typhoid  Fever.^^The  investigations 


Fig.    209. — Stages  in  Widal 
Reaction.       (After  Robin.') 


1  This  method  is  described  by  the  New  York  Health  Department. 


TYPHOID    FEVER.  651 

of  Griiber,  Witlal,  and  others,  published  in  1890,  showed  that  the  blood 
of  persons,  sutl'ering  from  or  having  recently  had  typhoid  fever,  contains, 
as  a  rule,  after  the  fifth  day  of  the  disease,  substances  which,  when  added 
to  a  broth  culture  of  the  typhoid  bacilli,  arrest  the  characteristic  move- 
ments of  these  organisms  and  cause  them  to  become  clumped  together  in 
masses. 

The  results  of  a  very  large  number  of  examinations  made  here  in  New 
York  and  elsewhere  show,  that  if  the  blood  contains  agglutinating  sub- 
stances in  sufficient  amount  to  cause  a  prompt  and  marked  reaction,  when 
one  part  of  serum  or  blood  solution  is  added  to  10  parts  of  a  broth  culture 
of  the  typhoid  bacillus,  the  presence  of  a  previous  or  existing  typhoid  in- 
fection may  be  considered  as  extremely  probable,  and  that  if  these  sub- 
stances are  present  in  such  an  amount  as  promptly  to  produce  the  reaction, 
when  1  part  of  serum  or  dried  blood  solution  is  added  to  20  parts  of  the 
culture,  the  presence  of  a  previous  or  existing  typhoid  infection  may,  for 
diagnostic  purposes,  be  practically  considered  as  established. 

In  estimating  the  diagnostic  value  of  a  negative  result  from  this  test, 
we  must  remember  that  the  reaction  is  rarely,  if  ever,  present  until  at  least 
four  days  after  the  appearance  of  symptoms;  that  it  is  occasionally  absent 
in  cases  of  typhoid  fever  until  the  third  or  fourth  week,  or  even  until  con- 
valescence is  established;  that  when  developed  it  may  disappear  after  a 
few  days,  and  that  no  definite  relation  between  the  severity  of  the  disease 
and  the  degree  and  time  of  development  of  the  substances  causing  the 
reaction  has  been  established.  For  these  reasons  a  single  negative  result 
in  any  suspected  case  only  renders  doubtful  the  existence  of  typhoid  fever. 
In  those  cases  in  which  the  reaction  is  absent  after  the  ninth  day,  it  may 
be  reasonably  assumed  that  the  large  majority  will  not  prove  to  be  typhoid 
fever,  and  the  absence  of  the  reaction  in  all  of  several  different  cases  of  a 
suspected  group,  or  after  repeated  examinations  in  any  single  case,  affords 
evidence  of  very  decided  value  in  excluding  the  diagnosis  of  t3q3hoid  fever. 

Directions  for  Preparing  Specimens  of  Blood. — The  skin  covering  the 
tip  of  the  finger  is  thoroughly  cleansed  and  then  pricked  with  a  clean 
needle  deeply  enough  to  cause  several  drops  of  blood  to  exude.  Two  large 
drops  are  then  placed  on  the  glass  slide,  one  near  either  end,  and  allowed 
to  dry  without  being  spread  out  on  the  surface  of  the  slide.  After  they 
have  dried,  the  slide  is  placed  in  the  holder  and  returned  in  the  addressed 
envelope  to  a  culture  station,  or  mailed  to  the  laboratory. 

The  diazo  reaction  should  be  looked  upon  as  a  valuable  aid  in  making 
the  diagnosis.  It  is  described  in  detail  in  the  chapter  on  "Urine,^^  page  883. 

The  Eruption. — The  eruption  consists  of  lenticular-shaped,  rose-col- 
ored spots.  They  are  small  and  slightly  elevated.  These  rose-colored  spots 
appeer  at  the  beginning  of  the  second  week.  The  eruption  lasts  about  ten 
days,  although  the  spots  last  from  two  to  three  days  and  are  succeeded  by 


652 


THE  INFECTIOUS  DISEASES. 


a  new  crop.  They  are  seen  on  the  thorax  and  abdomen,  although  at  times 
over  the  whole  body. 

Leucopcenia  if  present  strongly  supports  the  diagnosis  of  typhoid.  In 
the  International  Clinics  1909,  I  report  a  series  of  cases  in  which  the  white 
blood  cells  ranged  between  4000-6000  at  the  beginning  of  the  disease. 

Differential  Diagnosis. — Malaria  frequently  resembles  typhoid.     A  dif- 


Fig.    210.: — Typhoid  Fever.— Severe  haemorrhages.     Fatal  result.      (Original.) 

ferential  diagnosis  can  easily  be  made  by  an  examination  of  a  drop  of  blood 
for  the  presence  of  plasmodia. 

The  administration  of  quinine  is  a  diagnostic  test  of  practical  im- 
portance. An  irregular  or  iniermittent  fever  which  yields  promptly  to 
quinine  is  certainly  not  typhoid.  In  malaria,  the  temperature  will  be  found 
to  touch  normal  at  some  time  in  the  twenty-four  hours. 

Cholera  Infantum. — Many  cases  of  supposed  cholera  infantum  fre- 
duently  prove  to  be  typhoid  fever.     I  have  seen  many  cases  in  midsummer 


TYPHOID   FEVER.  653 

with  a  temperature  of  102°  ¥.,  having  roseola,  with  vomiting  and  diar- 
rhoea, in  such  cases  the  diagnosis  depends  on  the  presence  of  the  Widai 
reaction. 

When  diarrhoea!  symptoms  and  fever  are  present  in  the  early  stages 
of  typhoid  fever  it  is  extremely  difficult  to  make  a  diagnosis.  This  applies 
especially  to  the  first  week  of  the  disease  before  a  Widal  reaction  can  be 
made.  I  have  invariably  examined  the  urine  for  the  presence  of  indican 
(see  page  880).  When  the  symptoms  are  due  to  intestinal  autointoxication 
or  fermentative  conditions  in  the  intestine,  then  a  positive  indican  reaction 
is  present.  If  the  diazo-reaction  is  absent  and  indican  present,  we  can 
exclude  typhoid  fever. 

Internal  Iloemorrliages. — Holt  reports  a  series  of  946  collected  cases 
in  which  haemorrhage  occurred  in  30  cases,  about  3  per  cent.  The  ma- 
jority of  these  cases  were  over  10  years  of  age.  I  have  frequently  seen 
haemorrhages  in  children  between  5  and  10  years;  never  under  5  years. 

Case  I. — A  case  of  typhoid  in  a  boy  16  years  old,  seen  in  consultation  with  Dr. 
Rayewsky,  had  a  series  of  haemorrhages  which  ended  fatally.  The  origin  of  this  case 
was  supposed  to  be  an  infection  from  eating  raw  oysters.  The  boy  was  a  telegraph 
messenger  and  ate  some  oysters  in  the  street,  after  which  he  showed  signs  of  fever, 
and'  intestinal  symptoms.  No  other  etiological  factor  was  ascertained.  The  boy 
was  in  good  health  and  suddenly  became  ill  after  eating  this  meal  of  oysters.  Symp- 
toms of  gastric  fever,  with  diarrhoea;  temperature  of  101°  to  103°  F.  gradually 
appeared.  The  symptoms  increased  from  day  to  day  until  delirium  and  general  coma 
were  present.  The  fever  was  difficult  to  conti'ol  in  spite  of  cold  tub  bathing.  The 
boy  weakened  from  constant  pyrexia— appeared  to  convalesce — when  a  severe  haemor- 
rhage occurred.  An  ice-bag  was  laid  over  the  abdomen,  and  opium  given  internally. 
The  colon  was  flushed  with  alum  and  water.     Nothing  seemed  to  control  the  bleeding. 

Case  II. — A  girl,  10  years  old,  was  seen  in  consultation  with  Dr.  H.  Wein- 
stein.  She  had  been  sick  about  three  weeks  when  seen  by  me.  She  was  apparently 
convalescing  when  she  had  a  haemorrhage  of  a  very  alarming  nature.  The  doctor 
told  me  the  child  lost  more  than  one  pint  of  blood.  The  pulse  was  about  130  and 
very  feeble  in  character.  The  child  was  deathly  pale  and  seemed  to  be  in  collapse. 
Whisky  and  strychnine  were  ordered  as  restoratives.  The  child  complained  of  chills 
and  was  thoroughly  wrapped  in  warm  blankets  and  hot-water  bottles  were  applied 
to  her  feet.  A  teaspoonful  of  powered  alum  added  to  a  pint  of  cold  water  was  in- 
jected into  the  rectum  and  colon.  Paregoric  in  1.5  drop  doses  was  ordered  every  hour. 
The  nurse  was  instructed  to  watch  the  pupils  and  the  pulse  and  to  discontinue  the 
drug  as  soon  as  the  systemic  effect  of  the  paregoric  was  manifested.  Ice-crciini  was 
ordered  internally  and  small  pellets  of  cracked  ice.  The  child  recovered  after 
careful  dietetic  and  restorative  treatment. 

IniesUndl  Perforation. — Intestinal  perforation  is  very  rare.  It  is  met 
with  in  about  1  per  cent,  of  all  cases.  A  sudden  fall  in  the  temperature 
with  collapse,  rarely  vomiting,  followed  by  tympanites,  are  symptoms  indi- 
eatiug  perforation. 

Laparotomy  Wlien  Perforation  Occurs. — The  skill  of  the  surgeon  will 
frequently  save  life  when  hasmorrhages  occur.    In  a  case  of  typhoid  which 


654  The  ii^ECTious  diseases. 

progresses  favorably  during  the  third  and  fourth  week,  a  stidden  collapse 
should  be  an  indication  for  an  immediate  operation.  I  have  seen  death 
follow  a  case  of  this  kind.  These  cases  are  usually  hopeless  and  our  only 
chance  consists  in  resorting  to  an  immediate  operation. 

Complications. — Aphasia  is  occasionally  met  with.  Morse  reported  31 
cases.  Insanity  is  rarely  met  with  as  a  sequel  to  typhoid.  Chorea  is  fre- 
quently seen.  I  have  met  with  a  case  having  a  severe  form  of  choreiform 
movements  which  lasted  more  than  a  year,  following  the  attack  of  typhoid. 

Otitis  media  is  frequently  met  with  in  children.  It  is  very  important 
to  watch  the  ears  during  an  attack  of  typhoid. 

Less  frequent  complications  are  gangrenous  inflammation  of  the  mouth 
or  genitals,  pericarditis,  endocarditis,  peritonitis,  pyaemia,  abscesses,  and 
furuncles.  Abscess  of  the  liver  has  been  reported  by  Bokai.  Pulmonary 
tuberculosis  has  been  known  to  follow  typhoid. 

Prognosis  and  Course. — The  prognosis  is  more  favorable  in  children 
than  in  adults.  Tympanites,  if  accompanied  by  vomiting,  is  a  bad  sign. 
When  there  is  general  depression  and  nervous  symptoms  then  the  prog- 
nosis is  bad.  Singultus  is  usually  a  bad  sign.  Bleeding  should  always  be 
looked  upon,  especially  if  repeated,  as  a  bad  sign.  The  strength 
of  the  child,  its  assimilation  of  food,  and  the  condition  of  the  heart  should 
be  the  means  of  arriving  at  the  proper  prognosis.  Complications  should 
always  be  regarded  as  a  serious  matter.  The  prognosis  is  grave  if  the 
child  has  passed  through  a  typhoid  and  is  in  an  exhausted  condition,  and 
unable  to  cope  with  a  new  complication.  Baginsky  states  that  in  a  series 
of  68  cases  treated  by  him  in  the  hospital,  6  died,  a  mortality  of  8.8  per 
cent. 

In  children  typhoid  may  terminate  in  two  weeks.  It  may  extend', 
over  three  weeks  or  even  four  weeks.  Mild  cases  of  typhoid  resem- 
ble an  attack  of  acute  gastric  fever.  Cases  are  occasionally  seen  in  which, 
the  disease  terminates  abruptly  within  ten  days.  As  a  rule  older  children, 
show  the  adult  type  of  fever  and  the  disease  runs  its  course  of  three,  four,, 
or  six  weeks.  Infantile  typhoid  may  show  severe  gastric  symptoms,  such 
as  vomiting,  and  very  little  diarrhoea.  The  course,  therefore,  is  peculiar  to 
infants  and  entirely  different  from  that  seen  in  the  older  child. 

The  following  case  was  seen  by  me  some  time  ago.  A  woman,  35  years  of  age, 
was  taken  ill  with  typhoid  fever  of  a  very  severe  type.  She  nursed  her  infant  during 
the  first  week  of  her  fever.  The  infant  was  then  1  year  old.  The  physician  ordered 
the  infant  weaned.  About  one  week  later  the  infant  had  fever,  vomiting,  and  diar- 
rhoea. ,  An  examination  of  the  blood  gave  a  positive  Widal  reaction.  The  infant 
recovered  in  about  fifteen  days.  The  mother  died  of  hsemorrhages  during  the  third 
week  of  her  illness. 

Treatment. — The  specific  nature  of  the  disease  due  to  the  infection 
of  a  specific  germ,  has  caused  investigators  to  seek  a  typhoid  antitoxin.  As 
yet  no  definite  progi-ess  has  been  made  in  this  direction,  although  inves- 


TYPHOID    FEVER.  655 

tigators  have  from  time  to  time  announced  the  discovery  of  a  healing  serum.^ 
In  the  absence  of  a  specific  serum  we  must  confine  ourselves  to  the  treat- 
ment of  indications.  In  the  beginning  a  good  dose  of  calomel,  Yg  to  1 
grain,  repeated  several  times  a  day,  is  indicated. 

Fever  Treatment. — The  best  antipyretic  is  the  cold  bath  and  cold  pack. 
The  bath  must  be  properly  given  to  be  effective.  A  large  bath-tub  should 
be  procured,  large  enough  to  hold  the  child  at  full  length.  This  should 
be  half-filled  with  water  at  a  temperature  of  90°  F.  Cold  water  or,  in 
summer,  ice  should  be  added  until  the  temperature  is  gradually  reduced 
to  70°  F,  This  is  an  agreeable  method,  as  we  avoid  the  sudden  shock  so 
dreaded  by  children  when  suddenly  immersed  in  cold  water.  The  dura- 
tion of  the  bath  should  be  from  three  to  five  minutes. 

The  temperature  of  the  child  should  be  taken  before  and  after  the 
bath.  The  child's  body  should  be  rubbed  continuously  while  in  the  bath 
so  as  to  stimulate  the  circulation,  especially  so  when  the  water  is  cool.  If 
the  child^s  pulse  is  feeble,  administer  a  stimulant  such  as  hot  coffee  or 
whisky  before  the  bath.  Watch  the  pulse  carefully,  and  if  the  slightest 
sign  of  weakness  is  noted,  remove  the  child  immediately  from  the  bath 
and  place  in  bed  with  hot-water  bottles  to  its  feet.  The  bath  should  be 
repeated  every  three  or  four  hours  or  oftener,  if  the  temperature  requires 
it.     If  the  temperature  is  not  modified  lower  the  temperature  of  the  bath. 

Antipyretic  drugs,  such  as  napthaline,  benzoate  of  soda,  quinine,  anti- 
pyrin,  antifebrin,  phenacetin,  and  lactophenin,  are  useless  in  combating 
fever  when  compared  to  cold  baths  and  cold  packs.  All  antipyretic  drugs 
of  the  coal-tar  series  are  such  cardiac  depressants  that  they  should  never 
be  prescribed  without  combining  them  with  camphor  or  musk.  Of  all  anti- 
pyretic drugs  I  prefer  phenacetin.  One  of  the  best  antipyretic  measures  is 
the  injection  of  several  pints  of  cold  saline  solution  through  a  catheter  into 
the  colon.  Too  much  hydrostatic  pressure  should  not  be  used.  The  irri- 
gator should  be  held  about  one  foot  over  the  child's  body;  the  temperature 
of  the  water  should  be  between  60°  and  70°  F.  Flushing  the  colon  with 
cool  saline  solution  may  be  repeated  every  three  or  four  hours  if  a  good 
effect*  is  apparent.  When  great  exhaustion  and  a  weak  pulse  exist,  then 
^/a  teaspoonful  or  a  teaspoonful  of  alcohol  may  be  added  to  the  irrigation. 
The  main  point  to  remember  in  the  treatment  is  to  support  the  child  so 
that  the  strength  will  be  maintained  and  the  heart's  action  not  im- 
paired. With  this  object  in  view  nothing  is  better  than  restoring  vitality 
by  the  aid  of  concentrated  food.  When  there  is  great  exhaustion  the  admin- 
istration of  a  normal  salt  solution  per  rectum,  or  its  use  by  hypodcrmoclysis,* 
should  be  remembered.     One  or  two  pints  of  saline  solution  administered 


'  Einhorn,  of  New  Yo);k,  has  reported  beneficial  results  from  the  use  of  anti- 
typhoid serum. 

*  This  is  ilhistrated  in  detail  in  the  chapter  on  "Scarlet  Fever  Treatment." 


656  THE  INFECTIOUS  DISEASES. 

per  rectum,  with  the  hips  elevated,  is  frequently  the  means  of  stimulating 
diuresis,  thus  eliminating  the  poisons  of  the  toxins  through  the  kidneys. 
Great  care  is  required  in  giving  the  saline  in  the  form  of  hypodermoclysis. 
The  strictest  asepsis  should  be  maintained.  A  large  aspirating  needle 
attached  to  a  fountain  syringe  (Fig.  198)  is  well  adapted  in  an  emergency. 
These  saline  injections  may  be  repeated  every  six  or  twelve  hours  if  required. 

Hygienic  Measures. — Owing  to  the  infectious  nature  of  the  discharges 
passing  from  a  typhoid  patient,  the  prime  requisite  is  the  thorough  disin- 
fection of  all  stools  and  urine.  If  there  is  cough  or  sputum,  the  same  must 
also  be  thoroughly  disinfected.  In  fact  all  discharges  should  be  received 
in  a  vessel  containing  a  strong  solution  of  javelle  water  (chlorinated  lime) 
or  a  5  per  cent,  carbolic  solution.  A  strong  solution  of  copperas  should  be 
thrown  into  the  toilet  from  time  to  time  while  a  typhoid  patient  is  in  the 
house.  All  bed  linen,  handkerchiefs,  and  dishes  coming  in  contact  with 
the  patient  should  be  soaked  in  a  bichloride  solution  for  at  least  one-half 
hour  before  being  washed.  Sunlight  is  of  the  greatest  importance  in  a 
room  having  a  typhoid  patient.  We  can  do  more  disinfection  with  sunlight 
and  fresh  air  than  we  can  with  medication. 

The  Food. — All  food  must  be  liquid;  no  solid  food  should  be  allowed. 
In  the  beginning  whey,  strained  soups,  and  broths  should  be  ordered;  later 
strained  gruels,  cocoa,  acorii  cocoa,  and  chocolate  may  be  given  at  intervals 
of  two  or  three  hours.  In  some  cases  albumin  water,  made  by  beating  the 
raw  whites  of  two  eggs  with  sugar  and  water,  is  useful.  I  frequently  give 
the  whites  of  six  eggs  per  day.  Milk,  buttermilk,  kumyss,  whey,  or 
junket  may  be  given,  alternating  with  soups  and  broths.  When  stimulation 
is  required  the  yolk  of  egg  can  be  combined  with  sherry  or  Tokay  wine. 
When  drugs  are  given  it  is  best  to  combine  them  with  soups  or  broths. 
When  severe  dyspeptic  symptoms  exist,  predigested  milk,  peptonized  with 
the  aid  of  pancreatin  and  soda,  must  not  be  forgotten.  When  milk  idio- 
syncrasies exist,  then  the  yolk  of  a  raw  egg  added  to  barley  water,  rice 
water,  or  almond  milk  (made  by  blanching  almonds  with  hot  water)  can  be 
substituted  for  milk.  When  thirst  exists,  unfermented  grape  juice  or 
water  acidulated  with  dilute  phosphoric  acid  or  dilute  hydrochloric  acid 
is  very  grateful.  Ten  drops  of  either  dilute  acid  can  be  added  to  a 
tumblerful  of  sweetened  water,  and  this  given  whenever  the  child  is 
thirsty.  These  acids  have  a  very  good  effect  on  febrile  affections,  and 
are  especially  indicated  when  diarrhoea  exists. 

Feeding  in  Convalescence. — The  great  danger  of  hasmorrhage  should 
always  be  borne  in  mind ;  hence  it  is  advisable  to  abstain  from  giving  solid 
food  for  several  weeks  after  convalescence  is  thoroughly  established.  Soups 
thickened  with  sago,  farina  or  barley,  and  pea  and  lentil  soups  can  be  given. 
The  yolk  of  a  raw  egg  can  be  added  to  the  soup.  Milk  may  be  thickened 
with  zwieback.     The  main  diet  should  be  milk  and  cocoa  or  chocolate. 


TYPHOJD    FEVER.  (jo7 

Somatose  may  be  added  to  milk  or  sou]).  Plasmon  is  also  beneficial. 
Bovinine,  liquid  pcptonoids,  panopeptone,  eucasin,  or  tropon,  in  teaspoonful 
doses  added  to  milk,  are  very  valuable  during  the  convalescent  period. 
Valentine's  meat  juice  given  in  milk  or  soup  is  nutritious,  or  Mosquera's 
liquid  beef  (made  by  Parke,  Davis  &  Co.)  can  be  added  to  each  soup  or 
milk-feeding. 

Drug  Treatment. — If  cerebral  symptoms  exist,  then  an  ice-bag  should 
be  applied  to  the  head.  When  there  is  severe  restlessness  and  insomnia, 
with  twitchings  of  the  muscles,  then  injections  of  3  to  5  grains  of  chloral 
hydrate  should  be  tried  per  rectum.  These  injections  are  best  given  in 
starch  water.  Five-grain  doses  of  sulphonal  or  trional,  repeated  in  two 
hours  if  necessary,  is  sometimes  very  effectual. "  If  there  is  no  effect,  then 
V:.'4  grain  of  morphine  may  be  administered  hypodermically  for  a  child  2 
years  old. 

If  the  child  is  1  year  old,  then  V^g  grain  may  be  given,  and  repeated 
in  several  hours,  if  necessary.  The  greatest  care  must  be  maintained  if 
haemorrhage  exists. 

Bismuth  is  a  very  valuable  drug;  the  subnitrate  in  5  to  10-grain  doses, 
and  the  beta-naphthol,  in  5  to  10-grain  doses,  may  be  repeated  every  few 
hours  as  an  antifermentative. 

Tannalbin  or  tannigen,  in  doses  of  5  to  15  grains,  can  also  be  given 
every  two  hours.  If  the  hsemorrhage  is  very  severe,  then  an  injection  con- 
taining 30  drops  of  Monsell's  solution  added  to  a  quart  of  cool  water,  or 
a  teaspoonful  of  alum,  may  be  added  to  a  pint  of  water.  These  injections 
can  be  repeated  every  three  or  four  hours  until  the  haemorrhage  ceases. 
Ice-bags  should  be  kept  continuously  on  the  abdomen  at  the  slightest  sign 
of  hasmorrhage. 

Guaiacol  carbonate,  in  5  to  10-grain  doses,  repeated  every  three  or 
four  hours,  is  a  very  good  antipyretic.  Creosote  carbonate,  1  drop  for 
each  year;  for  a  child  1  year  old,  1  drop;  for  a  child  5  years  old,  5  drops, 
three  times  a  day,  is  one  of  the  best  intestinal  antiseptics. 

When  severe  tenesmus,  associated  with  flatulence  and  very  loose  stools, 
exists,  then  the  best  remedy  will  be  1  or  2-drop  doses  of  turpentine,  com- 
bined with  several  drops  of  paregoric.  The  oleoresin  of  turpentine  in  1 
or  2-grain  doses,  can  be  combined  M'ith  V^o  grain  of  extract  of  opium  for 
a  child,  5  years  old,  in  the  form  of  a  suppository.  This  can  be  repeated 
several  times  a  day  if  the  symptoms  are  not  improving. 

Prophylaxis. — The  injection  of  typhoid  vaccine  as  n  iii'oi)liyhu-tic  has 
been  described  in  Part  VII,  page  445. 


42 


CHAPTER  XIII. 


EEYSIPELAS. 


This  is  an  acute  infectious  and  contagious  disease.  It  is  characterized 
by  an  inflammatory  condition  of  the  skin,  the  subcutaneous  tissue,  the 
lymph  spaces,  and  the  lymph  vessels. 

Etiology  and  Bacteriology. — We  are  indebted  to  Fehleisen  for  a  study 
of  the  bacteriology  of  this  disease.  Fehleisen  found  the  streptococcus 
present,  so  that  it  is  positively  identified  as  the  cause  of  the  same.  The 
disease  may  also  originate  from  a  staphylococcus  aureus. 


^■^•iu 


^^^Z^Oh^ 


Fig.  211. — Ectogenous  Streptococcus  Infection.  Eczema  and  erysipelas 
of  the  scalp  in  a  child  1  month  old.  (Bacteria  carmine  stain)  ;  (a)  cutis; 
(6)  subcutis  ;  (c)  lymph  vessels  filled  with  streptococci,  surrounded  by  an  inflam- 
matory area  ;  (d)  epithelial  covering;  (e, /)  elevated  horny  layer;  (g)  strep- 
tococci.    X50.      (Ziegler.) 

TJie  invasion  of  the  micro-organism  takes  place  through  an  abrasion 
of  the  skin  caused  by  scratching  with  a  dirty  finger-nail.     It  is  very  rarely 
epidemic,  but  can  spread  easily  from  patient  to  patient.     A  case  of  ery- 
sipelas is  a  source  of  great  danger  in  a  hospital  ward. 
(G58) 


ERYSIPELAS. 


Cu)9 


Pathology. — Tliere  is  an  indltration  of  the  tissues  and  they  are  usually 
swollen  from  an  accumulation  of  serum.  Under  the  microscope  we  can  find 
pus  cells  in  the  serum.  When  this  condition  is  noted  abscesses  will  be 
found.  In  other  cases  gangrene  will  be  present.  Tliere  is  nothing  char- 
acteristic found  in  the  lungs,  heart,  kidneys,  spleen,  or  liver  which  would 
be  distinctly  pathognomonic.  The  usual  conditions  found  in  sepsis  are  seen 
here. 

Pneumonia  is 
sometimes  met  with  as 
a  complication. 

Symptoms.  —  The 
■usual  type  of  erysipelas 
met  with  in  children 
is  known  as  erysipelas 
migrans.  This  is  known 
as  the  wandering  type 
because  it  spreads  rap- 
idly from  diseased  to 
healthy  parts.  The  tem- 
perature in  the  begin- 
ning varies  from  102° 
to  103°  F.,  and  may 
rise  to  104°  or  105°  P. 
Septic  cases  usually 
show  a  much  lower  tem- 
perature. I  have  seen 
cases  of  a  decided  sep- 
tic nature  in  which  the 
temperature  was  99°  P. 
for  several  days.  The 
pulse-rate  varies  between  120  and  150.  The  flush  is  of  a  deep  red  color  and 
■usually  very  shiningo 

Complications. — The  oedema  usually  seen  on  the  skin  is  a  very  fatal 
complication  in  erysipelas  affecting  the  air  passages.  In  such  cases  oedema 
of  the  glottis  will  result  fatally. 

Prognosis. — This  depends  upon  tlie  time  when  the  case  is  first  seen 
and  chiefly  upon  the  condition  of  the  child  at  the  time  of  the  infection. 
If  the  child  is  well  nourished  and  has  been  breast-fed,  the  prognosis  is  good. 

Treatment. — A  dose  of  rhubarb  and  soda  or  5  to  10  grains  of  phos- 
phate of  soda  should  be  given.  The  destructive  tendency  of  tlie  pathogenic 
bacteria  on  the  blood  should  be  remembered ;  hence  large  quantities  of  nor- 
mal saline  solution  should  be  given,  by  injection,  into  the  colon.  The 
strictest  hygienic  measures  must  be  used.     The  internal  administration  of 


Ddte 

2 

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Fig.    212. — Fever  Curve  in  Facial  Erysipelas. 
(Original. ) 


560  ^E  INFECTIOUS  MSEASES. 


A  Study  of  the  Condition  of  the  Upper  Air  Passages  Before  and 

After  Intubation  of  the  Larynx.    Also,  an  Inquiry  Into 

the  Method  of  Feeding  Employed  in  the  Cases.^ 

Laryngeal  stenosis  will  frequently  be  relieved  after  one  intubation  and 
one  extubation.  There  are  other  cases  which  require  several  intubations 
before  a  permanent  cure  results. 

I  have  examined  a  series  of  children  that  were  operated  upon  several 
years  ago.  Two  classes  of  cases  have  been  selected.  One  series  was  seen  at 
the  Willard  Parker  Hospital,  and  the  cases  were  intubated  by  the  resident  or 
assistant  resident  physician.  The  cases  in  this  series  cover  the  years  1896 
to  1900,  and  were  under  treatment  of  Dr.  B.  G.  Bryant  and  Dr.  Somerset. 

First  Series.  Children  Intubated  in  the  Hospital. — The  children  ad- 
mitted to  the  Willard  Parker  Hospital  belong,  as  a  rule,  to  the  laboring 
class  of  people.  Exceptionally,  the  service  at  the,  hospital  receives  patients 
of  a  better  class.  All  of  the  children  examined  by  me  belonged  to  the  tene- 
ment house  district  of  New  York  City.  The  houses  are  densely  crowded 
tenements  having  a  minimum  quantity  of  fresh  air  and  sunlight.  It  is 
not  unusual  to  see  cases  from  such  unsanitary  surroundings  ending  fatally. 
These  children  are,  as  a  rule,  very  anaemic  and  are  extremely  susceptible  to 
infection. 

HospiTAX  Cases  :    10. 
8  cases  required  one      intubation 
1  case    required  three  intubations 
1  case    required  four    intubations 

Day  of  the  Disease. 

4  cases  were  intubated  on  tlie  2d    day  of  illness 

1  case    was    intubated  on  the  3d    day  of  illness 

2  cases  were  intubated  on  the  4th  day  of  illness 
1  case  was  intubated  on  the  5th  day  of  illness 
1  case  was  intubated  on  the  9th  day  of  illness 
1  case    was    intubated  on  the  14th  day  of  illness 

One  case  intubated  seven  years  ago  has  had  no  illness  since.  Four 
cases  intubated  six  years  ago  are  in  excellent  health  to-day.  One  case  has 
remained  entirely  well.  One  case  had  enlarged  cervical  lymph  nodes.  One 
case  had  pneumonia  one  year  later.  One  case  had  pneumonia  and  paralysis 
and  five  years  later  had  a  second  attack  of  diphtheria,  but  no  laryngeal 
stenosis. 

Five  cases  intubated  three  years  ago  are  in  good  condition  to-day. 
Three  had  measles  and  bronchitis  after  recovery.     One  has  not  had  a 


'■  Paper  read  before  the  International  Medical  Congress  held  at  Madrid,  Spain, 
April  26,  1903. 


INTUBATION.  561 

day's  illness  since  intubation.     One  case  had  a  mild  attack  of  croup  two 
years  after  intubation,  but  did  not  require  reintubation. 

Rachitis  seems  to  play  an  important  part  in  the  causation  of  laryngeal 
stenosis,  just  as  we  know  that  rickets  is  met  with  in  laryngismus  stridulus. 
Eight  cases  out  of  the  10  reported  in  this  series  showed  some  form  of 
rickets. 

There  seems  to  be  a  certain  predisposition  for  the  development  of 
laryngeal  stenosis  in  children  affected  with  diphtheria  who  are  rachitic. 

Condition  of  the  Throat. — In  all  of  the  cases  of  this  series  some  form 
of  chronic  tonsillar  or  pharyngeal  condition  was  found.  Adenoids  were  also 
seen  in  2  of  these  cases.  Whether  or  no  the  hypertrophied  tonsils  seen  in 
these  cases  were  present  at  the  time  of  intubation  is  not  known.  The  fact 
that  8  cases  out  of  10  still  showed  enlarged  tonsils,  and  1  case,  which  makes 
9  cases,  reported  having  had  a  tonsillotomy  performed,  proves  that  hyper- 
trophied tonsils  must  have  menaced  the  children's  health  before  the 
diphtheria. 

Feeding  During  Infancy. — It  is  certainly  an  interesting  fact  that  all 
of  the  children  in  this  series  were  breast-fed.  When  abnormal  conditions, 
as  rickets,  scurvy,  tuberculosis,  syphilis,  or  other  undermining  disorders, 
exist,  then  recurring  stenosis  of  the  larynx  might  possibly  be  provoked  by 
such  chronic  disease. 

These  cases  of  recurring  stenosis  sometimes  require  months  and,  in 
rare  instances,  years  of  intubating  until  recovery  takes  place.  I  have  fre- 
quently seen  chronic  tube  cases  while  making  my  rounds  in  the  wards  at  the 
Willard  Parker  Hospital. 

Intubation  has,  in  America,  entirely  replaced  tracheotomy  for  the 
relief  of  acute  lar}Tigeal  stenosis.  Eubber  tubes  are  used  exclusively  for 
intubation.  The  old  metallic  tubes  have  long  ago  been  discarded.  Trache- 
otomy is  used  as  a  secondary  operation,  usually  to  cure  "retained  tubes." 
When  laryngeal  stenosis  persists  and  the  patient  cannot  get  along  without 
the  tube,  then  a  tracheotomy  is  frequently  resorted  to. 

Jennings,  of  Detroit,  with  an  equally  large  experience,  says  that 
he  has  never  met  with  the  severer  forms  of  the  difficulty,  but  that  in  two  or 
three  instances  he  has  had  to  continue  the  intubation  as  late  as  the  third 
week  after  the  first  insertion,  before  recovery  was  complete.  His  associate, 
Shurley,  has  never  had  any  trouble  with  delay  in  the  removal  of  the  tube. 
G-alatti,  in  the  article  above  referred  to,  states  that  he  had  2  chronic 
stenoses  in  31  intubations.  He  reports  Eanke  as  having  had  1  case  in  many 
hundred;  Heubner,  1  in  250,  and  Bokay,  2  in  800.  McN"aughton,  of  Brook- 
lyn, says  that  he  has  had  but  few  cases  in  many  hundred,  and  these  recovered 
at  the  latest  within  several  weeks. 


36 


CHAPTEE  XIV. 
MALARIAL   FEVER      (INTERMITTENT    FEVER— PALUDAL   FEVEE— AGUE). 

This  is  a  specific  infectious  disease  due  to  the  invasion  of  a  distinct 
germ  belonging  to  the  class  of  protozoa.  It  is  known  as  the  plasmodium 
malariffi.  "The  disease  is  contracted  b}'  the  inoculation  of  the  human  sub- 
ject by  the  infected  mosquito.  The  plasmodium  malarise  passes  through 
one  cycle  of  its  development  in  the  body  of  a  variety  of  the  mosquito  known 
as  the  anopheles  cleviger.^' 

We  find  this  disease  in  Southern  Eussia  and  in  Italy;  in  our  own 
Southern  States  as  well.  In  the  Korth  of  Europe  and  the  Xorth  of  Amer- 
ica it  is  rarely  found.  The  disease  is  usually  seen  in  swampy  regions  and 
where  bad  drainage  exists.  It  is  also  seen  in  the  tropics.  The  influence  of 
the  weather  is  interesting.  While  in  summer,  spring,  and  fall  cases  occur 
frequently,  in  extremely  cold  weather  they  are  very  rare. 

Bacteriology  and  Etiology. — Laveran,  in  1880,  discovered  the  specific 
germ  which  causes  this  disease  in  the  blood  of  infected  individuals.  In 
America,  Councilman,  Abbott,  Osier,  and  many  others  have  confirmed 
Laveran's  observations.    There  are  several  types  of  fever. 

First. — The  middle  forms:  (a)  tertian,  double  tertian  (quotidian); 
(h)  quartan  fever  and  its  combinations. 

Second. — The  more  severe,  often  more  or  less  irregular  fevers  which 
occur  in  America  and  in  Italy,  most  commonly  at  the  end  of  the  summer 
and  fall,  called  the  gestivo-autumnal  fever  of  the  Italians.  The  tropical  ma- 
laria of  the  Germans.  This  type  of  fever  includes  the  so-called  remittent 
malarial  fevers  as  well  as  most  of  the  cases  of  pernicious  malaria  and  other 
malarial  cachexige. 

Tertian  Fever. — Golgi's  description  and  differentiation  of  the  micro- 
organism of  the  tertian  and  quartan  type  of  malaria  have  remained  prac- 
tically unassailed.  "If  we  examine  the  blood  from  a  case  of  tertian  fever 
just  after  the  paroxysm,  we  find  in  certain  of  the  red  blood-corpuscles 
small,  round,  colorless  bodies  which  appear  to  have  a  slight  depression  in 
the  center,  and  when  stained  in  dry  specimens  show  a  paler  central  area 
with  a  darker  periphery.  These  bodies  examined  in  the  fresh  specimen 
show  active  amoeboid  movements.  A  few  hours  later  the  organism  will  be 
found  to  have  increased  somewhat  in  size,  and  to  contain  a  few,  fine, 
brownish  pigment  granules  which  dance  actively  under  the  eye,  the  motion 
probably  being  due  to  undulatory  movements  in  the  protoplasm.  On  the 
dky  between  the  paroxysms  the  bodies  will  be  found  to  have  about  half- 
filled  the  red  corpuscles.  They  are  still  actively  amoeboid,  and  the  number 
of  pigment  granules  has  considerably  increased.  The  red  corpuscle  at  this 
stage  will  be  seen  to  be  a  trifle  larger  than  its  unaffected  neighbors,  and  to 
(662) 


MALARIAL    l-EVER.  (;03 

be  considerably  decolorized.  On  the  day  of  the  paroxysm  the  organism  has 
entirely  filled  and  almost  destroyed  the  red  blood-corpuscle,  which  is  rep- 
resented only  by  a  faint  pale  rim  about  the  full-grown  parasite,  if,  indeed, 
it  has  not  entirely  disappeared.  The  pigment  granules  may  show  at  this 
stage  a  very  active  motion,  but  the  amoeboid  movements  of  the  organism 
as  a  whole  are  but  little  marked.  At  the  time  of  the  paroxysm  an  interest- 
ing change  takes  place;  the  pigment  gathers  together  in  a  more  or  less 
solid  clump,  usually  in  the  center  of  the  organism,  while  the  rest  of  the 
protoplasm  looks  somewhat  granular  and  shows  a  suggestion  of  lines  radiat- 
ing outward  from  the  center.  This  appearance  gradually  changes,  the  lines 
becoming  more  distinct,  until  finally  we  see  the  central  clump  of  pigment 
surrounded  by  from  fifteen  to  twenty  small  ovoid  or  round  glistening  seg- 
ments, each  one  having  a  central  more  refractive  spot,  and  resembling 


Fig.    213.— Malaria  Plasmodia;   Ter-  Fig.    214. — ^Malaria  Plasmodia;  Trop- 

tian   Type.     Plehn-Chenzinsky's   Stain.  leal  Form.     Romanowsky-Xocht  Stain. 

X  1000.  X  1000. 

strongly  the  hyaline  bodies  which  we  see  immediately  following  the  chill. 
This  segmentation  of  the  organism  is  always  coincident  with  the  paroxysm, 
and  the  presence  of  the  blood  of  a  segmenting  body  is  a  sure  indication 
that  the  paroxysm  is  present,  or  is  about  to  occur.  Immediately  following 
the  paroxysm  fresh  hyaline  bodies  appear  in  the  red  corpuscles.  Though 
the  invasion  of  the  corpuscles  by  these  fresh  segments  has  never  been 
actually  observed,  the  evidence  that  this  occurs  is  so  strong  that  we  can 
safely  accejpt  it  as  a  fact.  Besides  these  forms  we  see  not  infrequently  small 
or  large  extra  cellular  pigmented  bodies;  that  is,  organisms  resembling 
exactly  those  within  the  red  blood-corpuscles,  excepting  that  they  are  free 
in  the  blood  current. 

These  may  be  seen  at  times  to  break  up  into  several  smaller  bodies, 
while  at  other  times  they  may  show  a  long,  tail-like,  non-motile  process 


GGi 


THE  INFECTIOUS  DISEASES. 


containing  sometimes  a  few  jVgment  granules.  They  are  probably  organ- 
isms which  have  escaped  from  the  red  corpuscles,  or  full-grown  bodies 
which  have  broken  up;  they  are  considered  to  be  degenerative  forms.  At 
times  also  we  find  the  so-called  flagellate  bodies.  Their  development  from 
the  pigmented  organism  may  indeed  be  observed,  the  pigment  of  the  full- 
grown  body  becoming  very  actively  motile,  then  collecting  in  the  center 
of  the  organism,  while  several  long,  thread-like  fiagella  burst  out  of  the 
body  and  move  actively  about  among  the  surrounding  corpuscles.  Some- 
times we  may  see  one  of  these  flagella  which  has  broken  away  from  the 
organism  and  is  moving  rapidly  through  the  field.  This  is  also  thought 
by  the  Italians  to  be  a  degenerative  process.  The  characteristics  of  this  form 
of  organism,  which  is  observed  in  tertian  fever  alone,  are  so  marked  that 
with  a  little  study  of  the  parasite  one  can  make  a  definite  diagnosis  of  the 
type  of  fever  from  an  examination. of  the  blood  alone. 


Date       1 

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Fig.  215. —  Tertian  Fever  (Intermittent  Fever).  Typical  malarial  tem- 
perature, usually  seen  in  the  spring  and  early  summer.  Onset  with  vomit- 
ing, diarrhoea  and  chills,  accompanied  by  a  well-marked  rigor,  and  coldness 
of  the  extremities.      (Original.) 


TliG  Parasite  of  Quartan  Fever. — "Quartan  fever  is  not  at  all  common 
in  this  country,  but  in  the  few  cases  which  the  writer  has  observed  the  or- 
ganisms differ  distinctly  from  the  tertian  parasite,  and  show  accurately  the 
characteristics  described  by  Golgi.  Here  the  first  stage  of  the  organism  is 
similar  to  that  observed  in  tertian  fever,  excepting  that  the  amoeboid  move- 
ments are  not  so  active.  As  the  body  develops,  the  rods  and  clumps  of  pig- 
ments are  larger  and  darker  than  those  in  tertian  fever,  while  the  amoeboid 
movements  of  the  organism  are  relatively  slight.  The  full-grown  forms  are 
materially  smaller  than  in  tertian  fever,  Avhile  the  red  blood-corpuscles, 
instead  of  being  expanded  and  decolorized,  appear  at  times  shrunken  about 
the  body,  and  of  a  somewhat  deeper  old-brass  color   (messingfarbe).     In 


MALARIAL    FEVER. 


no: 


segmentation  the  organism  divides  into  from  six  to  ten  different  parts  in- 
stead of  twenty  to  thirty,  as  in  the  tertian  form. 

The  Organisms  of  the  /liJslivo-aiUuinnal  Fevers. — "The  organisms  asso- 
ciated with  the  a'stivo-autunmal  fevers  have  heen  carefully  studied,  but 
much  remains  to  be  done,  ])articalarly  in  this  country. 

"There  is  some  difl'erence  of  opinion  as  to  whether  there  are  not  two 
types  of  organism  associated  with  these  fevers.  Some  Italian  observers 
divide  them  into  the  quotidian  and  tlie  malignant  tertian  organisms.  Tlie 
differences  made  out  by  the  Italians  arc,  however,  very  slight,  and  have  not 
been  observed  in  this  country.  In  the  first  place  we  see  just  after  the 
paroxysm  small  hyaline  bodies  which  may  or  may  not  be  actively  amoeboid; 
these  can  sometimes  be  distinguished  in  that  they  are  generally  somewhat 
smaller  and  have  oftentimes  a  characteristic  ring-like  appearance.  In  the 
early  stages — during  the  first  week,  for  instance — of  an  attack  of  this  form. 


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Fig.  216. — Quartan  Fever  (Double  Tertian).  Onset  with  vomiting  and 
convulsions.  Convulsions  usualh'  accompany  each  paroxysm.  Restlessne33 
associated  with  cyanosis  and  coldness  of  extremities.  These  cases  are  usually 
seen  in  the  late  autumn.     (Original.) 

we  may  see  only  the  hyaline,  mipigmented  forms;  but  commonly,  if  we 
observe  carefully,  we  may  sec  some  time  after  the  exacerbation  of  tem- 
perature, shortly  before  the  l)eginning  of  another,  bodies  which  are  a  trifle 
larger  than  tliese  smallest  hyaline  forms  and  which  contain  one  or  two  very 
minute  pigment  granules  lying  near  the  periphery.  Just  before  or  during 
the  paroxysm  we  may  see  bodies  with  a  small  central  clump  of  motile  or 
non-motile  })igment  granules  lying  usually  in  cells  which  are  more  or  less 
shrunken  and  crumpled,  and  of  a  deeper  color  than  the  normal  corpuscles 
(messingfarbe).  These  bodies  are  generally  not  half  as  large  as  the  red 
corpuscles.  After  the  first  week  or  ten  days  of  the  disease,  or  after  treat- 
ment has  l)een  begun,  we  see.  however,  certain  very  characteristic  and  easily 
recognizable  forms  which  ni-e  only  seen  with  this  type  of  fever.  These  are, 
first,  round  or  ovoid  bodies  about  the  size  of  a  red  corpuscle,  a  little  smaller 
or  a  little  larger,  with  clear,  rather  liighly  refractive,  waxy-looking  proto- 


G66 


THE  INFECTIOUS  DISEASES. 


plasm,  and  coarse  dark  pigment  granules,  which  are  nsually  collected  in  a 
ring  or  a  mass  in  the  center  of  the  organism.  The  granules  are  usuall}^  very 
slightly  motile.  At  one  side  of  the  body  we  often  see  a  small  bib-like  attach- 
ment which  may  show  a  slightly  yellowish  color.  On  examination  this  proves 
to  be  the  remains  of  the  red  blood-corpuscles  in  which  the  organism  has  de- 
veloped. In  association  with  these  are  seen  crescentic  bodies,  the  proto- 
plasm of  which  shows  the  same  characteristics  as  that  in  the  forms  above 
described,  while  the  pigment  is  collected  in  the  middle  in  a  similar  ring 
or  bunch,  and  is  but  slightly  motile.  On  the  concave  side  of  these  crescents 
one  may  also  often  see  a  bib-like  attachment,  just  as  in  the  ovoid  forms. 
At  times  during  the  examination  of  the  fresh  specimen  we  may  see  the 
change  from  an  ovoid  body  into  a  crescent  take  place,    The  development  of 


D.U:    1             .2                               3                              4                               5.                              6 

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Fig.  217. — ^stivo-aiitumnal  Fever  (mild  type).  Ushered  in  with  vomit- 
ing, restlessness  and  flushing.  The  spleen  is  enlarged.  Either  delirium  or 
drowsiness  and  somnolence  exists.      (Original.) 


these  forms  from  the  hyaline  bodies  can  be  followed  out  on  careful  ob- 
servation. They  are  thought  by  some  to  be  a  resting  stage  of  the  organism. 
Segmenting  bodies  are  almost  never  seen  in  the  circulating  blood  of  this 
form  of  malarial  fever,  though  the  presence  of  the  round  intracellular 
bodies  with  central  pigment  is  a  sure  sign  that  segmentation  is  going  on 
elsewhere.  It  has  been  found  by  the  Italians  that  after  the  accumulation 
of  a  few  pigment  granules  the  organisms  seek  the  internal  organs,  where 
segmentation  takes  place.  The  bodies  are  still  small  and  contained  within 
the  red  corpuscles.  The  pigment  gathers  in  the  center,  as  in  the  other  types 
of  segmentation,  while  the  segments  are  very  small  and  rarely  more  than 
twelve  in  number.  During  the  paroxysm  we  may  see  large  numbers  of  leu- 
cocytes containing  pigment  granules  and  clumps  which  are  probably  the 
remains  of  segmenting  organisms.  Flagellate  bodies  may  be  observed  here 
as  in  the  tertian  and  quartan  fevers,  but  only  when  ovoid  and  crescentic 
pigmented  bodies  are  present.    They  may  be  seen  to  develop  from  the  round 


MALARIAL    FEVER.  667 

bodies  with  central  pigment.  Careful  studies  concerning  the  morphological 
characteristics  of  the  malarial  parasite  have  shown  that  it  belongs  to  the 
class  of  protozoa,  and  is  possessed  of  a  nucleus  containing  one  or  more 
nucleoli.  At  the  time  of  sporullation  this  nucleus  divides — according  to 
some — directly,  according  to  others  by  karyokinesis." 

Pathology. — In  fatal  malaria  the  following  changes  are  found : — 

The  spleen  is  enlarged;  the  capsule  tense.  Death  has  been  reported 
from  rupture  of  the  spleen  (Thayer) .  The  pulp  of  the  spleen  contains  large 
numbers  of  red  blood-corpuscles  in  which  the  characteristic  parasite  is 
found.  "The  capillaries  are  usually  filled  with  the  plasmodia,  while  the 
•splenic  veins  show  relatively  few,  though  they  alwaj's  contain  large  cells 
enclosing  pigment  or  the  remains  of  red  corpuscles." 

The  Liver. — Small  areas  of  necrosis  are  described  by  Guarnieri :  "Xu- 
merous  liver  cells  are  found  containing  clumps  of  htematin  and  altered 
red  corpuscles,  a  condition,  similar  to  that  found  in  pernicious  anemia. 
Bignami  believes  that  this  may  explain  the  polycholia  found  in  cases  that 
died  of  pernicious  malaria." 

Examination  of  the  Blood. — A  small  drop  of  blood  should  be  taken 
from  the  ear  or  from  a  finger  ti|).  The  usual  aseptic  precautions,  such  as 
carefully  washing  the  finger  with  soap  and  water,  followed  by  a  washing 
with  alcohol  or  ether,  should  be  strictly  carried  out.  Fresh  blood  must  be 
examined  soon  after  it  has  been  withdrawn — ^no  later  than  three  or  four 
hours.  A  film  of  blood  can  be  preserved  if  the  air  is  excluded  by  smearing 
vaseline  around  the  edges  of  the  cover  glass.  The  amoeboid  movements  of 
the  protozoa  can  be  studied  in  this  fresh  blood.  Blood  for  examination 
should  1)e  drawn  about  one  hour  before  the  expected  paroxysm.  The  or- 
ganisms are  much  smaller  after  a  paroxysm. 

"The  tertian  parasite  completes  its  life  in  about  forty-eight  hours,  or 
less,  if  there  is  any  variation  from  this  time.  In  the  first  twelve  hours  of 
their  life  the  parasites  appear  as  small,  clear  specks  (hyaline  bodies)  in  the 
red  corpuscles,  and  if  any  pigment  is  to  be  seen  it  is  as  very  small  granules. 
If  stained  they  appear  pale  blue.  They  are  actively  amoeboid,  and  remain 
so  for  about  an  hour  after  withdrawal.  In  the  next  twelve  hours  the  para- 
sites have  grown  to  about  one-third  the  size  of  the  corpuscle,  are  still 
amoeboid,  show  fine  granules,  and  the  corpuscle  has  become  paler.  In 
the  next  twelve  hours  the  parasites  have  taken  up  about  two-thirds  of  the 
cell,  have  become  less  amoeboid ;  the  granules  larger  and  moving.  The 
parasites  are  now  more  irregular  in  shape,  and  the  corpuscles  larger  and 
paler,  the  pigment  granules  standing  out  more  markedly.  In  the  next 
twelve  hours  all  motion  ceases,  the  corpuscles  become  shells,  the  centers 
of  which  are  occupied  by  the  parasites,  and  spore  formation  and  segmenta- 
tion begin.  The  organisms  l)reak  up  into  fifteen  or  twenty  round  spores, 
at  first, contained  inside  the  cell-wall  of  the  red  corpuscles,  and  then  set  free 


668  THE  INFECTIOUS  DISEASES. 

into  the  blood.  It  is  at  this  time  that  tlie  clinical  paroxj'sm  occurs.  All 
hyaline  bodies  do  not  develop  to  the  stage  of  spore  formation,  nor  do  all 
these  spores — really  the  young  hyaline  bodies — which  have  been  set  free 
into  the  blood  serum  re-enter  the  red  corpuscles,  but  the  blood  plasma 
itself  destroys  many  of  them. 

"Should  we  have  under  observation  clinically  a  quotidian  form  of 
malaria,  the  red  corpuscles  would  show  the  tertian  parasite  in  but  two  stages 
of  development,  one  group  being  approximately  twenty-four  hours  older 
than  the  other ;  of  course,  depending  upon  the  hour  at  which  the  paroxysms 
occur.  This  is  due  to  a  double  infection.  It  must  not  be  forgotten,  however, 
that  we  may  have  a  triple  quartan  infection  that  produces  daily  paroxysms.. 

"The  quartan  parasite  grows  in  seventy-two  hours.  In  the  first  twelve 
hours  it  is  a  very  small,  unpigmented,  slightly  amoeboid,  hyaline  body,  be- 
coming in  twelve  hours  more  about  the  size  of  one-sixth  to  one-fifth  that 
of  the  corpuscle,  having  taken  on  a  few  pigmented  granules  placed  peri- 
pherally. In  forty-eight  hours  it  is  one-half  to  two-thirds  the  size  of  the 
red  corpuscle,  round,  as  a  rule,  and  possessing  no  amoeboid  movement.  In 
sixty  hours  from  the  paroxysm,  it  occupies  nearly  all  of  the  corpuscle, 
which  is  neither  enlarged  nor  paler  than  normal.  In  six  hours  more  the 
pigment  granules  approach  the  center  and  are  arranged  like  the  spokes  of 
a  wheel,  the  first  sign  of  segmentation.  About  three  hours  before  the  at- 
tack, segmentation  has  produced  from  six  to  ten  oval  or  pear-shaped  bodies 
or  spores  containing  pigment  in  their  centers.  In  multiple  infections  of 
this  type  we,  of  course,  find  the  organisms  in  the  blood  in  different  stages  of 
development.  Flagellated  bodies  develop  after  the  blood  is  removed  from 
the  body,  and  consist  of  a  central  cell  with  arms  thrown  out.  These  arms 
are  freely  movable.  In  examining  a  fresh  specimen,  we  may  see  such  a 
body  keeping  up  a  constant  ciliary  motion  and  causing  a  disturbance  in  the 
arrangement  of  the  red  cells  in  its  immediate  neighborhood.  The  flagellated 
body  does  not  often  appear  in  either  of  the  foregoing  types  of  the  infection, 
but  is  more  common  in  the  gestivo-autumnal  variety.  The  second  group  of 
parasites  belongs  to  the  class  of  malignant  or  asstivo-autumnal  figures,  and 
are  divided  into,  first,  the  pigmented  quotidian  parasite;  second,  the  un- 
pigmented quotidian  parasite;    and  tliird,  the  malignant  tertian. 

"The  pigmented  quotidian  parasite  completes  its  cycle  in  twenty-four 
hours.  When  seen  in  the  blood-corpuscle,  it  appears  as  a  small  actively 
amoeboid,  hyaline  body,  rapidly  becoming  pigmented  and  quiet,  the  pigment 
lodging  in  the  periphery  of  the  organism,  after  which  it  breaks  up  into 
spores.  It  has  been  pointed  out  that  segmentation  of  this  type  does  not  take 
place  in  the  peripheral  blood,  but  occurs  in  the  spleen  and  bone  marrow. 
The  pigmented  organism  occupies  one-third  of  the  corpuscle  which  is 
shrunken,  if  changed  at  all.  After  the  infection  has  lasted  for  several  clays 
crescents  appear. 


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670  THE  INFECTIOUS  DISEASES. 

"Crescents  are  always  an  evidence  of  cestivo-autumnal  fever^  and  never 
occur  in  the  quartan  or  tertian  type.  They  are  from  eight  to  ten  micro- 
millimeters  in  length  and  from  two  to  three  micromillimeters  in  breadth, 
are  half-moon  shaped  wlien  typical,  but  vary  greatly,  oftentimes  appear- 
ing almost  straight.  They  contain  pigment  sometimes  scattered,  but 
oftener  found  clumped  in  the  center,  and  usually  vsathout  motion.  With 
a  good  light  and  an  accurate  adjustment  the  shell  of  the  red  blood-cor- 
puscle can  be  seen  extending  from  the  poles  of  the  crescent,  showing  that 
this  parasite  is  distinctly  an  intracellular  formation.  Crescents  are  dis- 
tinctly an  evidence  that  the  infection  has  lasted  a  number  of  days, — five  or 
six — and  they  will  not  be  found  in  any  specimen  before  that  time.  The 
unpigmented  quotidian  parasite  shows  not  many  variations  from  the  fore- 
going type,  except  that  it  is  free  from  the  pigment,  though  the  crescents 
formed  from  this  variety  may  show  pigmentation.  The  malignant  tertian 
parasite  is  pigmented  and,  in  fact,  much  like  the  pigmented  quotidian.  It 
grows  to  segmentation  once  in  forty-eight  hours,  and  is  amoeboid  in  the  ad- 
vanced stage ;  the  pigment  is  active  and  the  entire  organism  is  larger.  Prob- 
ably no  better  idea  can  be  given  concisely  of  the  different  characteristics  of 
these  parasites  than  by  reproducing  the  table  of  Mannaberg.'^     (See  p.  669). 

Symptoms. — In  very  young  children  there  may  be  convulsions,  restless- 
ness, cold  extremities,  and  yawning.  The  pulse  is  full  and  rapid.  The  tem- 
perature may  reach  as  high  as  105°  F.,  or  even  higher.  After  this  febrile 
stage  the  body  is  covered  with  a  profiise  perspiration,  ending  in  sleep  from 
exhaustion.  Diarrhoea  is  ocasionally  met  with  in  this  condition,  and  is  prob- 
ably the  result  of  secondary  infection.  Bronchitis  is  occasionally  seen.  The 
paroxysm  of  fever  occurs  when  the  protozoa  matures  and  begins  to  divide. 
This  process  repeats  itself  about  every  twenty-four  hours  in  the  tertian  type 
of  intermittent  fever  most  frequently  seen  in  this  country.  If  children 
are  carefully  observed,  then  the  onset  of  a  paroxysm  is  frequently  seen 
by  a  severe  cyanosis  affecting  the  nails.  This  would  correspond  to  the 
chill  seeji  in  the  older  children.  Slight  albuminuria  or  hematuria  fre- 
quently accompanies  malaria.  There  is  no  disease  that  can  be  mistaken 
for  the  tertian  type  of  malaria  when  it  is  remembered  that  there  is  a  sick 
day  with  fever,  etc.,  and  an  alternating  apparently  healthy  day. 

An  enlarged  spleen  is  usually  present. 

Diagnosis. — This  can  be  most  positively  made  by  an,  examination  of 
the  blood.  So  many  symptoms  present  in  malaria,  such  as  lassitude,  pains 
in  the  bones,  headache  and  fever,  simulate  other  diseases,  that  only  the  posi- 
tive finding  of  Laveran's  protozoa  in  the  blood  will  complete  the  diagnosis. 

Differential  Diagnosis. — If  there  is  a  doubt  as  to  the  differential  diag- 
nosis between  tuberculosis  and  malaria,  the  specific  effect  of  a  few  doses  of 
quinine  will  easily  show  the  presence  or  absence  of  malaria.  The  blood  test 
is,  however,  conclusive. 


MALARIAL   FEVER.  671 

A  boy,  6  years  old,  was  brought  to  me  at  the  children's  service  of  the  German 
Poliklinik  with  a  history  of  headache,  fever,  and  pain  in  the  bones.  The  boy  ap- 
peared rather  icteric.  His  mother  said  that  he  had  lost  weight  during  the  last 
two  weeks.  He  perspired  freelj%  had  a  good  day  and  a  bad  day.  The  fever  appeared 
in  the  afternoon.  The  examination  showed  a  well-nourished  boy,  lungs  normal,  a 
slight  hiemic  murmur  at  the  apex  of  the  heart  which  was  also  heard  in  the  vessels 
at  the  neck.  The  spleen  was  palpable  and  slightly  enlarged.  The  appetite  was  poor, 
the  bowels  moved  sluggishly.  The  child  was  restless  at  night.  The  examination 
of  the  blood  showed  the  presence  of  the  ordinary  tertian  parasite.  Quinine  in  3- 
grain  doses  was  given  every  four  hours,  and  6  grains  were  given  three  hours  before 
the  expected  attack,  which  in  this  condition  was  between  1  and  2  o'clock  in  the 
afternoon.  Fifteen  drops  of  cascara  sagrada  were  administered  before  breakfast 
of  each  day.  The  treatment  was  continued  for  ten  days.  Tlie  boy  then  complained 
of  buzzing  in  the  ears,  evidently  due  to  cinchonism.  Quinine  was  given  every  second 
day  and  Fowler's  solution  in  3-drop  doses  was  administered  on  alternate  days. 
Strengthening  food  was  given  and  the  child  made  a  complete  recoverj'.  Quinine  was 
given  once  every  three  days  after  the  first  month.  The  child  took  an  ocean 
voyage  and  was  perfectly  well  in  two  months.  Iron  was  then  given  for  several 
months  as  a  tonic  and  the  treatment  discontinued. 

Prognosis. — This  is  usually  good.  If  malaria  is  neglected  severe  an- 
aemia follows,  and  if  pernicious  malaria  results  it  ma}'  end  in  death.  In 
this  country  the  specific  effect  of  quinine  and  the  change  of  climate  usually 
gives  successful  results. 

Treatment. — A  patient  suffering  with  malaria  should,  if  possible,  be 
removed  to  a  different  climate.  A  change  from  the  city  to  the  country. 
or  vice  versa,  is  very  beneficial.  Next  in  importance  to  change  of  air  is 
the  specific  effect  of  quinine.  Five  grains  of  quinine  (0.3)  can  be  given 
to  a  child  3  years  old.  The  hydrochlorate  of  quinine  is  the  most  effective. 
Owing  to  its  disagreeable  taste  it  can  be  given  in  tablet  form,  after  which 
a  mouthful  of  coffee  or  chocolate  can  be  given.  "When  quinine  is  refused 
by  mouth,  then  a  10-grain  dose  in  the  form  of  a  suppository  can  be  given 
three  times  a  day,  per  rectum.  The  hest  time  for  administering  quinine  is 
about  three  hours  before  the  expected  attack.  The  bisulphate  of  quinine 
is  a  soluble  and  convenient  form  to  use.  It  is  very  important  to  keep  the 
bowels  open  and  the  kidneys  active.  Fifteen  to  30  drops  of  fluid  extract 
of  cascara  sagrada  can  be  given  in  a  palatable  menstruum  every  morning, 
so  that  the  action  of  the  bowel  is  assisted.  In  true  malaria,  I  have  found 
especial  benefit  in  administering  whisky  well  diluted  with  water,  or  given 
in  milk.  Apart  from  its  nutritive  properties,  it  certainly  has  decided  anti- 
septic properties.  If  malaria  persists  in  spite  of  continued  treatment,  then 
arsenious  acid  in  doses  of  ^/-^oq  or  ^/j-q  grain,  can  be  administered  three 
times  a  day.  Fowler's  solution,  in  doses  of  1  to  5  drops,  should  not  be 
forgotten.  Jacobi  recommends  ergot  in  doses  of  20  to  50  drops  every  day 
for  weeks.  When  it  is  not  well  borne  he  combines  it  with  quinine  or  arsenic. 
I  have  never  been  able  to  see  the  slightest  benefit  from  the  use  of  ergot, 
although  I  have  tried  it  in  many  cases.  I  believe  Jacobi's  results  were  good 
when  he  combined  the  ergot  with  the  quinine  because  the  quinine  was  given. 


CHAPTER   XV.  , 

SYPHILIS. 

This  is  a  specific  disease  most  probably  caused  by  the  invasion  of  a 
micro-organism  called  SpirocJiCBta  pallida.  The  disease  in  infancy  is  the 
same  as  that  in  adults.    There  are  two  forms  of  the  disease: — 

1.  Inherited  s}'philis. 

2.  Acquired  syphilis. 

Etiology. — The  most  frequent  modes  of  infection  are : — 
By  nursing  from  the  breast  of  a  syphilitic  wet-nurse. 
Eating  from  the  dishes  of  syphilitic  patients. 

Unclean  surgical  instruments;  for  example,  when  an  infant  is  vac- 
cinated, or  during  the  operation  of  circumcision. 

The  Trojismission  of  Syphilis  in  Utero. — An  infant  in  utero  may  be 
infected  directly  through  the  circulation  in  the  placenta.  If  the  mother 
acquires  syphilis  during  the  ninth  month  of  her  pregnancy,  the  same  will 
not  infect  her  child  nor  modify  its  development.  A  healthy  infant  in 
utero  can  be  infected  by  passing  through  a  syphilitic  genital  tract  of  its 
mother  during  labor. 

When  the  ovum  is  infected  with  syphilis,  which  frequently  happens 
at  the  time  of  conception,  it  may  terminate  in  the  death  of  the  foetus,  re- 
sulting in  an  abortion  or  in  the  birth  of  a  still-born  child.  If  the  child 
lives  it  may  suffer  with  cachexia,  and  a  few  weeks  later  present  the  char- 
acteristic skin-lesions.  The  father  can  infect  the  mother  for  three  or,  at 
the  most,  five  years  after  his  chancre.  The  father  may  infect  the  foetus  as 
late  as  twenty  years  after  his  chancre,  when  for  years  he  has  presented  no 
signs  of  syphilis.  The  mother  may  have  a  series  of  syphilitic  pregnancies 
resulting  in  miscarriages  or  in  s^-philitic  infants,  without  at  any  time 
herself  presenting  any  s3-philitic  manifestations.  In  the  same  couple  the 
severity  of  the  infection  transmitted  to  the  fatus  tends  to  decrease  with 
succeeding  pregnancies.  Thus  it  is  the  rule  for  the  mother  to  have  at 
first  several  abortions,  then  a  child  born  dead,  and  finally  a  living  child 
showing  the  evidences  of  inherited  s^'philis.  Children  born  later  usually 
suffer  less  severely,  Ijut  this  "law  of  decreases"  (Diday)  is  not  without  nu- 
merous exceptions;  sometimes  the  third  or  fourth  child  suffers  more  than 
the  second.  In  other  families  children  of  one  sex  suffer  more  than  those 
of  the  opposite  sex.  In  twin  pregnancies  one  may  be  affected  while  the 
other  apparently  escapes.  The  apparent  escape  of  the  mother  of  syphilitic 
infants  by  a  syphilitic  father  has  been  accounted  for  on  the  supposition 


(67 


9' 


SYPHILIS.  673 

f 

that  she  undergoes  a  mitigated  infection  derived  from  the  foetus.  Coutts^ 
has  pointed  out  the  theory  that  she  absorbs  from  the  foetus  a  syphilitic  anti- 
toxin ;  this  would  account  not  only  for  her  apparent  immunity,  but  also  for 
the  gradual  decrease  in  the  severity  of  the  disease  in  later  pregnancies.  If 
the  mother  be  infected  but  not  the  father,  death  of  the  foetus  is  the  most 
likely  result.  If  the  child  is  born  alive  it  will  probably  suffer  from  in- 
herited syphilis.  If  both  parents  have  suffered  from  manifest  syphilis,  the 
chance  of  abortion  or  still-birth  is  greater. 

Golles's  .Law. — In  1837  Colles  wrote  that  "A  new-bom  child  affected 
with  inherited  syphilis,  even  though  it  may  have  specific  lesions  in  the 
mouth,  never  causes  infection  of  the  breast  which  it  sucks  if  it  be  the  mother 
who  nurses  it,  although  continuing  capable  of  infecting  a  strange  nurse." 
The  substantial  truth  of  this  dictum  has  not  been  seriously  questioned, 
though  various  explanations  have  been  offered. 

Butyric-acid  Test  for  Syphilis.^ — This  test  depends  on  the  precipitation 
of  globulin,  either  in  the  blood-serum  or  in  the  cerebrospinal  fluid.  The 
Noguchi  test  consists  of  the  following: — 

From  one-tenth  to  two-tenths  c.c.  of  cerebrospinal  fluid,  which  is 
absolutely  free  from  blood,  is  mixed  with  one-half  c.c.  of  a  10  per  cent, 
solution  of  butyric  acid  in  normal  saline,  and  boiled.  Then  one-tenth  c.c. 
of  4  per  cent,  sodium  hydroxid  solution  is  quickly  added,  and  the  whole 
boiled  for  a  few  seconds.  A  granular  or  floccular  precipitate  means  a 
positive  reaction.  The  precipitate  appearing  within  a  few  minutes  indicates 
a  large  increase  in  globulin,  while  a  weaker  reaction  may  not  appear  for 
an  hour  or  two,  two  hours  being  the  time  limit. 

If  this  test  gives  the  spinal  fluid  only  a  slight  opalescence  or  tur- 
bidity and  no  granular  precipitate,  then  we  can  consider  the  fluid  normal 
after  the  usual  time  limit  has  been  reached. 

With  the  cerebrospinal  fluid,  a  positive  reaction  occurs  in  any  case 
of  syphilitic  or  parasyphilitic  affection;  also  in  all  acute  or  chronic  in- 
flanmaations  of  the  meninges,  whether  due  to  the  meningococcus,  the  tubercle 
bacillus,  the  pneumococcus,  the  streptococcus,  or  the  influenza  bacillus.  In 
the  early  stage  of  poliomyelitis  the  reaction  is  also  positive.  In  acute  luetic 
meningitis  the  presence  of  Treponema  pallidum  in  the  cerebrospinal  fluid 
will  serve  to  exclude  other  forms  of  meningitis. 

In  hydrocephalus,  the  cerebrospinal  fluid  gives  a  positive  butyric-acid 
test  in  cases  which  are  of  syphilitic  origin.  In  pneumonia,  with  an  in- 
creased amount  of  cerebrospinal  fluid  without  iuflanmiation  of  the  meninges, 
the  fluid  does  not  give  a  positive  butyric-acid  test. 


*  "Some  Aspects  of  Infantile  Syphilis."    Hunterian  Lectures,  London,  1897. 
^I  am  indebted  to  Dr.  Hideyo  Noguchi  for  assistance  in  the  preparation  of 
this  article. 

43 


674 


THE  INFECTIOUS  DISEASES, 


The  test  is  most  valuable  in  differentiating  between  inflammatory  and 
non-inflammatory  conditions  of  the  meninges  in  children.  The  blood-serum 
test  is  too  complicated  to  be  tried  outside  of  a  highly  equipped  laboratory. 

Pathological  Anatomy. — In  obscure  inflammatory  lesions  involving  the 
meninges  or  spinal  cord,  it  is  necessary  to  submit  the  spinal  fluid  as  well 
as  the  blood  to  the  Noguchi  or  the  Wassermann  test.  While  the  Noguchi 
test  is  very  sensitive,  one  should  not  fail  to  utilize  the  Wassermann  to 
confirm  the  presence  or  absence  of  a  positive  reaction.  In  acquired  syphilis 
changes  are  the  same  in  the  child  as  in  the  adult. 


Fig.    218. — Spirochseta  pallida.     Macerated  skin  of  foetus. 
(Courtesy  of  the  Rockefeller  Institute,  New  York.) 


In  hereditary  syphilis  there  are  certain  constant  changes  present  in 
the  bones.  These  changes  are  confined  to  the  shafts  of  the  long  bones  and 
to  the  cranial  bones. 

The  pathological  changes  are  not  confined  to  'the  epiphyses,  but  the 
diaphyses  are  also  swollen.  The  ends  of  the  bones  are  swollen.  The  inner 
portion  of  the  periosteum  shows  swelling  and  hypersemia. 

The  circulatory  apparatus  shows  thickening  of  the  arterial  walls  as 
well  as  of  the  veins.  Owing  to  this  degeneration  there  is  a  tendency  to 
bleeding.     (See  clinical  case  described  in  this  chapter.) 

Catarrhal  manifestations  showing  implication  of  the  respiratory  tract. 


SYPHILIS.  675 

and  also  the  gastro-intestinal  tract,  can  be  noted.  The  liver,  spleen,  and 
pancreas  are  enlarged. 

The  lymph  glands  of  the  entire  body  are  enlarged. 

Symptoms. — When  catarrh  is  troublesome  in  children  and  not  amen- 
able to  ordinary  treatment,  syphilis  should  be  suspected.  It  is  surprising 
to  find  the  frequency  with  which  nasal  and  nasopharyngeal  catarrh  is  asso- 
ciated with  syphilis.  I  have  not  yet  had  occasion  to  regret  asking  a  direct 
question  of  a  parent  in  whom  I  suspected  syphilis,  if  such  parent  is  told 
that  we  must  know  his  previous  history,  for  the  benefit  of  his  child. 

Gastro-intestinal  Tract. — The  gastro-intestinal  tract  is  the  one  that 
will  frequently  show  the  manifestations  of  syphilis.  An  infant  will  not 
appear  to  thrive  nor  will  it  digest,  in  spite  of  the  most  careful  dietetic  meas- 
ures. Syphilitic  lesions  of  the  liver,  pancreas,  stomach,  and  intestine  are 
simply  all  part  of  the  infection.  Anti-luetic  treatment  will  frequently  do 
more  good  in  a  few  days  or  weeks  than  months  of  rigid  diet.  Thus  it  is 
apparent  that  in  order  to  do  good  in  this  disease  we  must  seek  to  remove 
the  cause. 

When  a  persistent  diarrhoea  will  not  respond  to  the  ordinary  treat- 
ment of  careful  diet  and  medication,  then  suspect  syphilis.  When  diar- 
rhoea such  as  a  mucus-colitis  persists  without  fever  after  careful  dieting, 
then  syphilis  may  be  suspected. 

The  following  case  will  illustrate  congenital  syphilis : — 

An  infant  about  one  week  old  was  seen  by  me.  It  was  the  fourth  child  of 
apparently  healthy  parents.  Three  children  had  previously  died,  and  this  fourth 
child  was  born  at  full  term.  The  mother  noticed  that  the  child  cried  incessantly  and 
was  very  restless.  The  child  had  had  sniffles  since  birth.  It  was  breast-fed  and 
appeared  to  suffer  with  colic  and  hunger.  The  stools  were  grass-green  and  con- 
tained mucus  and  curds.  The  palms  and  soles  had  a  pemphigus.  The  skin  had  a 
yellowish  tinge.  The  nose  was  excoriated  from  the  discharge.  The  anus  had  deep 
cracks — the  so-called  rhagades.  Around  the  mouth  were  also  rhagades.  The 
spleen  was  enlarged  and  palpable.  The  lymph  glands  were  not  enlarged.  Tlie  chill 
did  not  seem  to  thrive.  The  finger  nails  showed  distinct  evidences  of  the  disease. 
The  bones  of  the  fingers  and  toes  showed  the  presence  of  dactylitis  syphilitica.  The 
diagnosis  of  congenital  syphilis  was  made.  The  mother  had  plenty  of  milk,  but 
was  compelled  to  wean  the  child  owing  to  a  typhoidal  condition  to  which  she  suc- 
cumbed. The  infant  was  bottle-fed,  and  when  about  five  weeks  old  developed  a  large 
abscess  on  the  forearm  which  was  incised  under  an  anaesthetic  by  Dr.  Geo.  F.  Shrady. 
One  week  later  a  series  of  metastatic  abscesses  formed  over  the  abdomen  and  on 
the  back.  The  child  died  from  inanition  and  general  sepsis  when  about  nine  weeks 
old. 

Hemorrhages  from  the  nose  and  mouth,  and  bloody  stools  due  to  ulcer- 
ation of  the  intestinal  tract  are  frequently  reported. 

Uracek  has  reported  haemorrhages  in  the  different  internal  organs 
caused  by  syphilis  in  the  infant.  Umbilical  hjemorrhages  are  sometimes 
due  to  syphilis,  according  to  Eotch. 


676  THE  INFECTIOUS  DISEASES. 

The  following  case  will  illustrate  bleeding  in  the  new-bom : — 
An  infant  suffered  with  a  severe  form  of  marasmus  and  athrepsia.  It  did  not 
develop.  Examination  of  the  mucous  membrane  of  its  mouth,  gums,  and  fauces 
showed  distinct  patches.  The  child  was  attended  by  Dr.  Honor,  of  New  York  City, 
who  referred  the  case  to  Dr.  W.  Freudenthal  for  diagnosis.  The  case  was  also  seen 
by  me  and  I  concurred  in  the  opinion  expressed,  that  the  patches  were  non- 
diphtheritic  and  were  most  likely  due  to  syphilis.  Several  days  later  Dr.  Freudenthal 
and  myself  were  again  called  to  see  this  child  owing  to  an  extensive  nasal  haemor- 
rhage. In  spite  of  the  most  active  local  treatment,  the  use  of  haemostatics,  such  as 
adrenalin,  and  the  use  of  styptics  internally  and  externally,  the  infant  died  from 
exhaustion.  The  attending  physician.  Dr.  Honor^  subsequently  stated  that  he  had 
found  distinct  evidence  of  syphilis. 

SMn  Lesions. — The  skin  lesions  develop  soon  after  those  of  the  mu- 
cous membrane.  The  eruption  consists  of  small,  round,  pink  macules,  which 
disappear  on  pressure.  While  the  eruption  may  be  on  the  abdomen  and 
lower  limbs,  it  not  infrequently  is  found  all  over  the  body.  At  times  the 
eruption  resembles  an  erythema  and  is  copper-colored.  Sometimes  the 
eruption  is  papular;  it  is  not  infrequent  to  find  condylomata  around  the 
mouth  or  anus.  These  cond3domata  are  very  contagious.  Pustules  are 
frequently  seen  as  early  as  two  months.  This  eruption  can  be  differentiated 
from  eczema  by  the  characteristic  absence  of  itching  that  always  accom- 
panies eczema.  Furuncles  are  usually  found  in  poorly  nourished  children. 
The  infant  usually  has  the  appearance  of  a  shriveled  old  man. 

The  Teeth. — The  teeth  in  congenital  syphilis,  instead  of  appearing  at 
the  sixth  or  seventh  month,  may  not  appear  until  the  fourteenth  or  fif- 
teenth month,  and  even  later.    These  teeth  are  usually  carious. 

Congenital  Syphilitic  or  Hutchinson's  Teeth. — This  variety  of  dental 
abnormality  is  important,  because,  as  Hutchinson  says,  "It  is,,, if  taken 
alone,  by  far  the  most  valuable  of  the  signs  by  which  we  recognize  in 
adolescence  the  effect  of  inherited  syphilis."  The  characteristics  of  these 
teeth  are  not  sufficiently  known,  and  abnormal  and  peculiar  teeth  of  other 
kinds  are  often  erroneously  regarded  as  proofs  of  congenital  syphilis.  The 
main  points  about  "Hutchinson's  teeth"  are  as  follows : — 

1.  It  is  always  the  permanent  teeth  which  are  affected.  The  tem- 
porary teeth  in  syphilitic  infants  often  decay  early,  but  they  present  no 
special  peculiarities  of  form. 

2.  The  characteristic  peculiarities  which  distinguish  these  central 
incisors  are  as  follows :  They  are  dwarfed,  being  too  short  and  too  narrow ; 
and  sometimes  the  portion  of  the  upper  jaw  from  which  they  grow  is  also 
arrested  in  growth.  They  often  stand  somewhat  apart  and  slope  toward 
one  another.  They  are  unusually  rounded  on  section;  they  are  "pegged" 
and  they  are  notched.  The  notch  is  usually  shallow  and  the  dentine  is 
exposed  at  the  bottom  of  it.  It  is  formed  by  the  breaking  away  of  the 
imperfectly  developed  central  portion  of  the  edge.    The  teeth  are  generally 


SYPHILIS. 


677 


not  of  a  good  color,  and  they  are  abnormally  soft,  so  that  by  the  time  the 
patient  is  20  they  may  be  ground  down  like  those  of  an  old  man. 

The  first  molars  are  next  in  diagnostic  importance  to  the  upper  cen- 
tral incisors.  When  characteristic  they  are  spoken  of  as  "dome-topped." 
Their  sides  slope  toward  the  center,  over  which  the  enamel  is  defective.    As 


Fig.    219. — Syphilis.     Child  14  years  old.     A  productive  periostitis  enclosing  the 
shafts  of  the  long  bones.     Absolutely  characteristic  of  syphilis. 


might  be  expected,  syphilitic  teeth  not  infrequently  present  the  character- 
istics of  mercurial  teeth  in  addition  to  their  own  peculiarities. 

Diagnosis  and  Differential  Diagnosis.^ — The  clinical  history  will  be  the 
guide  in  congenital  syphilis.  The  history  of  previous  abortions  and  still- 
born children  will  aid  in  establishing  a  diagnosis. 

The  cachectic  skin,  the  wrinkled  mouth,  and  rhagades  at  both  mouth 
and  anus  will  materially  aid  in  establishing  a  diagnosis. 

'  See  "Blood  in  Syphilis,"  page  685, 


678  THE  INFECTIOUS  DISEASES. 

Table  No.  68. — Differential  Points  Between  Syphilis  and  Tuberculosis. 

(Morrow.) 

SYPHIUS.  TTJBEBCUIiOSIS. 

Exhibits  a  marked  predilection  for  the  Is  almost  exclusively  situated  in  the 

long  bones;    its  habitual  localization  is  epiphysis,    rarely  affecting  the   shaft, 
in  the  diaphysis  and  almost  always   at 
its  terminal  extremity. 

There  is  a  marked  enlargement  of  the  The  tumefaction  is  due  less  to  increase 
bone  by  more  or  less  voluminous  osseous  in  the  size  of  the  bone  than  to  oedema- 
tumors  or  hyperostoses,  with  little  or  no  tons  infiltration  of  the  soft  structures, 
involvement  of  the  soft  parts. 

There  is  little  tendency  to  suppuration  The  pyogenic  tendency  is  marked, 
and  necrosis. 

Osteocopic  pains  with  tendency  to  The  pain  is  dull  and  hea^^,  not  aggra- 
nocturnal  exacerbation  are  pronounced  vated  at  night;  sometimes  there  is  en- 
features,  tire  absence  of  acute  painful  symptoms. 

The  osseous  lesions  rarely  react  upon  The  osseous  lesions  often  determine  a 

the  general   system.  marked     impairment     of     the     general 

health,  grave  complications,  hectic  fever, 
cachexia,   etc. 

In    dactylitis    there    is    little    involve-  In  dactylitis  the  swelling  is  due  more 

ment   of    the    soft    parts,    the    swelling  to  an  (edematous  infiltrated  condition  of 

being  caused  by  the  enlargement  in  the  the  soft  tissues  than  to  enlargement  of 

size  of  the  bone.  the  bone.     Breaking-down  of  the  tissues 

and  ulceration  are  more  apt  to  ensue. 

At  times  pseudo-paralysis  will  be  present;  sometimes  coryza,  hoarse- 
ness, inflamed  eyes,  and  persistently  running  ears. 

The  Wms&rmann  Reaction. — In  suspicious  cases  the  blood  should  be 
examined  to  see  if  we  get  a  positive  Wassermann  reaction. 

Luetin  Test. — This  reaction  devised  by  Noguchi  is  apparently  specific 
for  syphilis.  It  is  useful  after  the  spirochete  can  no  longer  be  demonstrated, 
and  when  the  Treponema  pallidum  still  survives  in  the  body.  As  a  rule  90 
per  cent,  of  hereditary  syphilis  gives  a  positive  reaction.  Under  1  year 
the  reaction  is  indistinct;  from  2  to  6  years  it  gradually  increases.  Late 
cases  are  almost  always  positive.  Exceptions  are  few.  Cases  with  a  strong 
Wassermann  reaction  and  clinically  unfavorable  cases  give  a  negative 
reaiction. 

An  emulsion  of  pure  culture  of  Treponema  pallidum  is  prepared  and 
0.057  cubic  centimeter  is  injected  under  the  skin  by  means  of  a  fine  needle. 
If  a  red,  indurated  papule  forms  after  twenty-eight  to  forty-eight  hours, 
surrounded    by  a  diffuse  zone  of  redness,  the  reaction  is  positive. 

This  redness  increases  for  three  to  four  days,  then  disappears  within 
a  week.    A  slight  rise  of  temperature  may  accompany  this  reaction. 

"The  diagnosis  between  syphilis  and  rachitic  bone  lesions  may  become 
of  great  importance.  Epiphyseal  swellings  occurring  under  six  months  are 
apt  to  be  syphilitic.  In  syphilis  the  epiphyseal  swelling  may  be  unilateral, 
but  it  is  always  symmetric  in  rachitis.    In  doubtful  eases  the  swelling  must 


SYPHILIS. 


679 


Fiff.    220. 


Fig.    221. 


Fig.    222. 


Fiff.    2-23. 


Figs.  220-223.— Syphilitic  Teeth.  Various  types  of  hereditary  syphilitic 
teeth,  as  described  by  Hutchinson;  also  parenchymatous  keratitis.  Note 
that  the  upper  central  incisors  show  the  positive  evidence  of  syphilis. 
(Courtesy  of  Dr.  Hugo  Neumann.) 


680 


THE  INFECTIOUS  DISEASES. 


be  subjected  to  specific  treatment.  Rickets  and  syphilis  may  coexist  in  the 
same  case.  There  is  almost  invariably  enlargement  at  the  costochondral 
articulations  in  all  cases  of  rickets,  which  is  absent  in  syphilis.-" 

Prognosis. — This  depends  upon  the  condition  of  the  child  at  the  time 
treatment  is  commenced.    Such  children  have  very  little  or  no  vitality. 

Hereditary  syphilis  can  be  transmitted  to  healthy  children,  so  that 
the  precaution  of  strict  isolation  should  be  remembered. 

Treatment. — ^The  therapy  of  sj^philis  has  undergone  a  radical  change 
since  the  introduction  of  salvarsan.    Through  the  courtesy  of  Prof.  Ehrlich, 


Fig.    224. — Congenital  Syphilis  Before  Injection  of  Salvarsan.      (Original.) 

I  received  a  liberal  supply  of  salvarsan,  also  known  as  dioxydiamidoarseno- 
benzol  or  "606." 

ISTo  case  should  be  injected  until  a  positive  Wassermann  reaction  has 
been  obtained.  The  choice  of  the  technique  of  the  injection  is  one  of 
preference,  although  the  intravenous  method  seems  most  popular  because 
of  better  results.  The  following  doses  are  recommended :  For  an  infant  1 
year  old,  an  injection  of  0.06  gramme,  to  be  followed  in  one  week  by  an 
injection  of  0.1  gramme  (intravenous  method)  if  no  severe  systemic  reaction 
follows  the  first  injection.  For  a  child  5  years  old  an  injection  of  0.1 
gramme,  followed  one  week  later  by  an  injection  of  0.2  gramme.  Complica- 
tions must  be  guarded  against.  When  we  recall  that  one-third  of  salvarsan 
consists  of  arsenic,  then  the  toxicity  of  the  same  is  well  brought  out.  By  the 
intravenous  method  we  diffuse  the  efficiency  of  this  drug  into  the  circula- 
tion and  prevent  the  cumulative  effect  which  usually  follows  the  intramus- 
cular injection, 


SYPHILIS. 


681 


In  one  of  my  cases^  severe  necrosis  of  the  tissues  in  the  gluteal  region 
was  followed  by  a  series  of  deep  abscesses.  In  addition  thereto,  a  multiple 
neuritis  developed  which  involved  the  lower  limbs  and  persisted  until  five 
months  after  the  injection  was  given.  The  syphilitic  ulcerations  and 
condylomata  around  the  vagina  and  anus  improved  after  three  or  four  days 
and  practically  disappeared.  This  child  was  18  months  old  and  received 
0.3  of  an  alkaline  solution  of  salvarsan  injected  into  the  gluteal  region. 

B.  L.,  six  years  old,  a  former  patient  of  Dr.  Tunick,  was  admitted  to  the 
babies'  ward   of  the   Sydenham  Hospital.      The   mother   had  an   innocent   infection. 


Fig.    225. — Appearance  of  Lesions  One  Week  Aft«r  Injection  of 
Salvarsan.      (Original.) 


The  child  showed  distinct  evidences  of  syphilis.  Two  years  previous  a  gumma  of 
the  left  testicle  existed,  and  said  testicle  was  removed.  At  time  of  admission  he 
had  very  marked  superficial  veins,  periostitis,  and  gumma  of  the  left  knee-joint. 
The  Wassermann  reaction  and  the  Noguchi  reaction  were  positive.  All  serological 
examinations  were  made  by  Dr.  D.  M.  Kaplan. 

One  injection  of  0.3  salvarsan,  in  a  neutral  solution,  was  given,  with  aseptic 
precautions  in  the  left  buttock.  No  local  reaction  followed.  The  child  made  a 
brilliant  recovery.  The  swelling  in  joint  subsided  after  three  days.  The  boy  walked 
in  one  week  and  was  discharged  two  weeks  after  admission. 

Local  Treatment. — The  safest  method  of  administering  mercury  is 
in  the  form  of  bichloride  baths.     These  baths  can  be  given  in  a  wooden 


'Reported  in  the  Journal  of  Americap  Medical  Association,  February  11,  1911, 


682  THE  INFECTIOUS  DISEASES. 

tub,  in  which  enough  water  is  drawn  to  cover  the  child's  body.  From  5 
to  10  grains  of  bichloride  can  be  added  to  this  tub  of  water.  Infants  up  to 
1  year  can  be  bathed  from  ten  to  twenty  minutes  every  day. 

The  presence  of  eczematous  or  other  skin  eruptions  would  not  contra- 
indicate  giving  these  baths. 

The  inunction  of  chemically  pure  mercurial  ointment  well  rubbed  into 
the  axillae,  knee-joints,  or  the  thighs  will  materially  aid  in  bringing  this 
drug  into  the  system. 

For  the  relief  of  syphilitic  warts  nothing  is  better  than: — 

IJ  Bichloride  10  parts 

Alcohol    100  parts 

Apply  with  absorbent  cotton  several  times  a  day. 

Internal  Treatment. — Internally  calomel  and  bichloride  or  the  tannate 
of  mercury  can  be  given  in  suitable  doses.  It  is  advisable  to  give  the  child 
from  1  to  5  grains  of  iodide  of  sodium,  according  to  age,  to  alternate  with 
the  mercurial  treatment. 

Care  should  be  taken  that  stomatitis  is  not  developed  in  nurslings.  If, 
however,  stomatitis  has  developed,  then  active  and  persistent  treatment  with 
chlorate  of  potash  solution,  locally,  will  be  found  effectual. 

It  is  self-understood  that  hygienic  treatment  in  addition  to  careful 
diet  is  just  as  important  as  the  specific  drug  treatment. 

Feeding. — A  diet  of  milk,  eggs,  cereals,  fish,  and  fruit  should  form  the 
basis  of  nutrition.  The  reader  is  referred  to  the  articles  on  "Marasmus" 
and  "Eickets"  as  a  guide  to  the  method  of  feeding  necessary  to  reconstruct 
a  weakened  child. 


PAKT  VIII. 

DISEASES  OF  THE  BLOOD,  GLANDS  OK  LYMPH  NODES, 
AND  DUCTLESS  GLANDS. 


CHAPTER  I. 
INTRODUCTORY. 

The  Blood.^ 


The  red  corpuscles  (also  known  as  the  erythrocytes).  The  red  cor- 
puscles of  the  blood  are  more  numerous  at  birth  than  in  later  life.  Hayem 
and  Helot  found  that  when  the  umbilical  cord  was  not  tied  until  its  pulsa- 
tions ceased,  a  greater  number  of  red  corpuscles  were  found  than  in  cases 
where  immediate  ligation  was  performed.  Leder  and  Hutchinson,  com- 
paring the  new  infant's  blood  with  that  of  its  mother,  found  that  the  blood 
of  the  infant  contained  a  larger  number  of  red  corpuscles.  The  following 
table  will  show  the  difference  in  blood  count  by  various  writers : — 

Table  No.  69. 
Hayem    averaged  5,360,000 


Sorensen    

Otto   

Bouchat  and  Dubrisay    .  .  .  . 

SchiflF    (one   case)     

Gundobin    

Elder  and  Hutchinson    . .  .  , 
Schwinger  greatest  at  birth. 


5,665,000 
6,165,000 
4,300,000 
6,658,000 
6,700,000 
5,346,560 


The  difference  varies  between  350,000  and  500,000  per  cubic  milli- 
meter. Gundobin  believed  that  the  concentration  of  the  blood  was  caused 
by  loss  of  water  through  the  lungs.  Schiff  found  the  same  condition;  he 
also  states  that  the  number  of  corpuscles  decreases  when  the  child  is  put  to 
the  breast.  The  number  of  red  corpuscles  begins  to  fall  after  the  second 
day. 

In  one  case  Schiff  studied  the  number  in  the  morning  and  evening 
during  the  first  fifteen  days  of  life ;  he  found  the  number  declined  irregu- 
larly. The  first  day's  count  was  7,628,000 ;  the  last  day's  count  was  4,565,- 
600;  the  average  for  the  fifteen  days  was  5,828,465. 

According  to  Schwinger  and  Gundobin,  there  is  a  decrease  in  the 
number  during  the  first  year ;  after  this  there  is  an  increase  up  to  the  eighth 


*I  am  indebted  to  Stengel  and  White,  Archives  of  Pediatrics,  April,  1901,  for 
many  valuable  points  in  the  preparation  of  this  article. 

(683) 


684  DISEASES  OF  THE  BLOOD. 

or  twelfth  year,  when  the  number  becomes  approximately  that  of  adult  life. 
Sex  makes  no  difference  in  the  count  of  the  red  corpuscles  in  infancy. 

Size. — The  red  corpuscles  vary  greatly  in  size  at  birth  and  during  the 
first  few  days  of  life.  Hayem  found  variations  between  3.25  fx  and  10.25  ^ 
and  Ix)OB  found  the  size  varying  from  3.3  r/  to  10.3  m.  Gundobin  claims 
that  the  hemoglobin  is  more  firmly  attached  to  the  cell  stroma  in  the  new- 
bom  infant.  He  also  calls  attention  to  the  great  number  of  small-sized 
corpuscles. 

The  Ecemoglohin. — According  to  Morse,  Elder,  Hutchiason,  Taylor, 
and  Eotch,  haemoglobin  is  increased  at  birth,  but  the  percentage  declines 
rapidly  during  the  first  few  days  of  life.  According  to  Eieder,  there  is  an 
excess  of  25  to  30  per  cent,  at  birth  compared  with  infants  after  feeding 
has  begun. 

Specific  Gravity. — This  varies  just  like  the  haemoglobin.  At  birth  the 
specific  gravity  is  high. 

Monti   found  the   specific  gravity  at  birth    1060 

Eotch  found  the  specific  gravity  at  birth    1065 

Hoch  &  Schlesinger  found  the  specific  gravity  at  birth    ....  1066 

Moelle  found  the  specific  gravity  at  birth 1060 

The  specific  gravity  may  not  vary  for  weeks  or  months  in  healthy 
children. 

The  White  Blood  Corpuscles  (Leucocytes). — Leucoc}i;es  are  found  in 
greater  number  at  birth  than  in  later  life.  This  excess  in  number  has  fre- 
quently been,  spoken  of  as  a  normal  condition.  It  is  also  called  the  physio- 
logical leucocytosis  of  the  new-horn. 

Table  No.  70. 
Physiological  Leucocytosis.  Pathological  Leucocytosis. 

1.  Leucocytosis  of  the  newborn.  1.  Inflammatory     and     infectious     leuco- 

cytosis. 

2.  Digestion  leucocytosis.  2.  Leucocytosis  of  malignant   disease. 

3.  Leucocytosis     due     to     thermal     and       3.  Toxic  leucocytosis. 
mechanical   influences. 

4.  Thermal  leucocytosis.  4.  Experimental  leucocytosis. 

Pathological  Conditions. — In  disease  the  first  change  noticed  will  be 
a  reduction  in  the  percentage  of  haemoglobin,  and  also  in  the  number  of 
erythrocytes.    There  are  smaller  forms  of  red  corpuscles  called  microcytes. 

Nucleated  Red  Corpuscles  (Erythrohlasts) . — These  cells  have  been 
found  in  primary  and  secondary  anaemias  by  many  observers.  They  have 
also  been  found  very  abundant  in  syphilis,  rachitis,  tuberculosis,  pseudo- 
leukaemia,  and  osteomyelitis, 

Leucocytosis. — In  leucocytosis  an  increase  in  the  number  of  leucocytes 
is  found  in  the  blood  of  anemic  children.    It  is  also  found  in  toxic  and 


THE  BLOOD.  685 

inflammatory  conditions.  Myelocytes  are  more  frequently  found  in  the 
blood  of  children  than  in  adults.  Cabot  and  Engel  ascribe  a  bad  prog- 
nostic significance  in  pneumonias  and  diphtherias  to  their  presence. 

Acute  colitis  causes  concentration  of  blood,  with  considerable  leu- 
cocytosis. 

Inflammatory  leucocytosis  is  classified,  according  to  Cabot,  as  follows : — 

1.  Infection  mild;  resistance  good;  small  leucocytosis. 

2.  Infection  less;  mild;  resistance  good;  moderate  leucocytosis. 

3.  Infection  severe;  resistance  good;  very  moderate  leucocytosis. 

4.  Infection  severe;  resistance  poor;  no  leucocytosis. 

Table  No.  71. 

Red  hloodr corpuscles.  Leucocytes. 

Birth   5,900,000  21,000 

Seventh    day    5,000,000  15,000 

First   year    5,000,000  10,000 

Sixth    year     5,000,000  7,500 

(Coles.) 
Proportion  of  Leucocytes  in  Adults  and  Infants. 

Adults.  Infants. 

Small  uninueleated   24  to  30  per  cent.  50  to  75  per  cent. 

Large  uninueleated   3  to    6  per  cent.  6  to  14  per  cent. 

Multinucleated   or   neutrophils    ...    60  to  75  per  cent.  28  to  40  per  cent. 

Eosinophile    cells     1  to    2  per  cent.  %  to  10  per  cent. 

In  studying  a  series  of  blood  counts  in  babies,  Warfield  found  the 
younger  the  infant  the  higher  the  leucocyte  count.  Gundobin  and  Carstanjen 
found  that  the  increase  is  due  chiefly  to  an  excessive  gain  in  the  polynuclear 
neutrophiles. 

Infectious  Diseases. — In  diphtheria,  scarlatina,  pneumonia,  and  ery- 
sipelas the  polymorphonuclear  cells  are  greatly  increased  (Weiss  and  Gun- 
dobin). Gundobin  found  an  increase  in  the  number  of  leucocytes  before  the 
eruption  in  scarlet  fever,  measles,  and  erysipelas.  In  typhoid  fever  the 
number  of  leucocytes  is  decreased ;  there  may  be  also  a  decrease  in '  the 
number  of  red  corpuscles  and  in  the  percentage  of  hgemoglobin.  The  num- 
ber of  leucocytes  is  relatively  increased.  The  polymorphonuclear  cells  are 
decreased. 

Pneumonia. — Leucocytosis  is  usually  present  in  this  disease.  When  it 
is  absent  the  prognosis  is  grave. 

Sypliilis. — In  hereditary  syphilis  an  ansemia  is  found  with  a  decrease 
of  the  red  corpuscles  and  great  degenerative  changes  (poikilocytosis).  In 
syphilis  we  find  microcytes  and  macrocytes  and  nucleated  erythrocytes. 
Myelocytes  are  also  found.    Eosinophiles  are  also  met  with  in  this  condition. 

Bronchitis. — A  slight  leucocytosis  with  especial  increase  of  the  lympho- 
cytes or  mononuclear  cells. 


686  DISEASES  OF  THE  BLOOD. 

Gastro-intestinaX  Disease. — The  condition  of  the  blood  varies  accord- 
ing to  the  extent  of  the  process,  the  duration,  and  the  existence  or  non- 
existence of  diarrhoea  and  vomiting.  Profuse  diarrhoea  and  vomiting  may 
for  a  time  thicken  the  blood  by  loss  of  water.  Weiss  shows  an  increase  of 
the  leucocytes  and  transitional  leucocytes. 

Rachitis. — ^There  is  usually  a  reduction  in  the  number  of  red  corpuscles, 
a  decrease  in  the  percentage  of  haemoglobin,  and  an  accompanying  leueo- 
cytosis  according  to  von  Jaksch. 

STcin  Diseases. — There  is  an  increase  in  the  number  of  eosinophiles. 
The  cause  of  the  same  is  unknown. 

Nervous  Diseases. — In  the  functional  disorders  of  childhood  the  blood 
findings  are  those  of  a  moderate  anaemia.  Burr  has  found  that  the  blood 
in  chorea  is  not  as  a  rule  anaemic.  In  my  own  examinations  (Fischer)  the 
opposite  result  has  been  found,  and  I  believe  that  in  prolonged  chorea  a 
distinct  leucocytosis  can  be  found. 

Blood  Reaction  of  Pus. — The  glycogenic  reaction  of  the  blood  has  fre- 
quently been  described  in  literature.  The  first  complete  paper  on  this 
subject  was  published  by  Dr.  M.  Goldberger  and  Dr.  Siegfried  Weiss.^  This 
diagnostic  aid  is  of  value  when  a  questionable  diagnosis  exists.  ( 

When  an  abscess  exists,  especially  if  it  is  localized,  there  is  invariably  a 
marked  leucocytosis,  even  in  limited  suppurative  foci.  In  the  subcutaneous 
or  interstitial  connective  tissue  there  is  always  a  high  leucocytosis.  Ewing 
found  marked  leucocytosis  in  the  active  stages  of  otitis  and  all  suppurative 
processes  which  subsided  rapidly  after  the  operation.  There  was  one 
exception  in  abscess  of  the  liver  with  mucopurulent  exudate. 

Iodine  Reaction  (lodophilia). — This  reaction  consists  in  slight  or 
intense  reddish-brown  granules  and  a  diffuse  brown  coloring  of  the  entire 
protoplasm.  The  protoplasm  of  the  polynuclear  neutrophile  leucocytes 
shows  a  marked  affinity  for  iodine.  This  intracellular  iodine  reaction  is 
present  in  purulent  conditions  and  persists  as  long  as  suppuration  is  present. 
It  has  an  important  diagnostic  bearing  when  abscesses  are  deep  seated. 
Cabot  and  Locke^  obtained  uniformly  positive  reactions  in  septicemia, 
pneumonia,  empyema,  and  suppurative  appendicitis;  in  serous  pleural 
effusions  and  in  catarrhal  appendicitis  the  test  was  negative.  In  about 
one-half  of  the  cases  of  enteric  fever  examiued  by  these  writers  the  test  was 
positive,  usually,  only  in  those  complicated  by  haemorrhage,  perforation, 
furanculosis,  or  lung  lesions.  These  studies  have  been  more  recently  sub- 
stantiated by  Gulland.^ 

The  following  table,  prepared  by  Casper  Sharpless,  will  assist  in  the 
differentiation  of  the  blood : — 


"■  Wiener  klinisehe  Wochenschrift,  No.  25,  1897. 

*  Journal  of  Medical  Research,  1902,  vol.  vii. 

•  British  Medical  Journal,  1904,  vol.  i. 


PLATE  XXXI 

louoiMiiLiA.     Pus  Reaction  of  Blood. 


Coverglass  Specimen  of  Blood  in  a  Case  of  Suppurative  Appendicitis. 
a,  Polynuclear  leucocytes;  6,  polynuclear  leucocytes  containing  many  irreg- 
ular granules  of  glycogen;  c,  extra-cellular  iodine-stained  masses,  giving  the 
reaction  of  glycogen. 


a,  Pus  corpuscles  without  iodine  reaction;   b,  pus  corpuscles,  iodine  reaction. 

(Original.) 


THE  BLOOD. 

Table  No.  72. 


687 


Disease. 

Leucocytosis. 

Lymphocytes. 

Neutrophiles. 

Red  Cells. 

Hjemoglobin. 

Typhoid  Fever 

Absent 

Relatively 
increased 

Decreased 

Decreased 

Proportionately 
decreased 

Typhoid  with 
complications 

Present 

•  Increased 

Decreased 

Proportionately 
decreased 

Scarlet  fever    . 

Present 

Decreased 

Increased 

Decreased 

Proportionately 
decreased 

Measles.   .    •    • 

Absent 

No  change 

No  change 

Small  pox    .    . 

Marked  on 
third  day 

Increased 

Much  de- 
creased 

Proportionately 
decreased 

Erysipelas    .    . 

Marked 

Increased 

Decreased 

Proportionately 
decreased 

Diphtheria  .    . 

Marked 

Earely 
increased 

Increased 

Slight  de- 
crease 

Proportionately 
decreased 

Influenza .    .    . 

No  change 

No  change 

No  change 

Typhus  fever 

No  change 

No  change 

No  change 

Follicular 
tonsillitis 

Moderate 

No  change 

Acute  rheu- 
matism . 

Moderate 

Increased 

Markedly 
decreased 

Markedly 
decreased 

Septicaemia .    ■ 

Marked 

Increased 

Markedly 
decreased 

Proportionately 
decreased 

Abscess.    .    .    , 

Marked 

Increased 

Decreased 

Proportionately 
decreased 

Meningitis  . 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Peritonitis  •    • 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Pericarditis .    . 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Pleurisy  .    . 

Marked 

Increased 

Slightly 
decreased 

Proportionately 
decreased 

Malaria    .    . 

Absent 

Eelatively 
increased 

Decreased 

Decreased 

Proportionately 
decreased 

Pneumonia '    . 
Appendicitis 

Marked 
Marked 

Decreased 

Increased 

Decreased 

Proportionately 
decreased 

•  In  pneumonia  there  is  a  decrease  of  the  eosinophiles  and  in  scarlet  fever  an  increase. 

Table  No.  73. 


Reaction  Absent  in 
Serous  pleural  efi'usion. 


Reaction  Present  in 
Empyema. 

Suppurative  appendicitis.  Catarrhal    appendicitis. 

Enteric   fever  when   complicated  by   fu-       Enteric  fever  when  uncomplicated. 

runculosis  or  pulmonary  lesions. 
Gonorrheal  arthritis.  Rheumatic  arthritis. 

Influenza.  Pure  tuberculous  abscesses. 

Cerebrospinal  meningitis. 
Sepsis    ( septicemia) . 


588  DISEASES  OF  THE  BLOOD, 

The  persistence  of  this  reaction  after  the  incision  of  a  pns  cavity  sug- 
gests, frequentl}^,  imperfect  drainage. 

The  staining  solution  as  advised  by  Goldberger  and  Weiss^  is  as 
-follows:— ' 

lodin     1 

Potassium    iodid 3 

Distilled  water 100 

Mix  and  add  sufficient  gum  arable    (about  50   parts)    to  make  a 
syrupy  mixture. 

With  a  camePs-hair  brush  a  layer  of  this  solution  is  painted  over  the 
surface  of  the  dried  unfixed  blood  film,  upon  which  it  is  allowed  to  act  for 
from  one  to  five  minutes.  The  excess  is  then  removed  by  blotting  with  a 
bit  of  filter  paper,  and  the  specimen  is  mounted  in  cedar  oil.  Or,  as  Wolfl! 
advises,  Zollikofer's  method  may  be  used :  placing  the  fresh  film  for  a  few 
minutes  in  a  stoppered  bottle  containing  crystals  of  pure  iodine.  In  films 
thus  treated  the  iodine  reaction  is  recognized  by  a  slight  or  intense,  diffuse 
brown  coloring  of  the  entire  protoplasm,  or  by  the  presence  throughout  the 
protoplasm  -  of  numerous  intensely  stained,  reddish-brown  granules,  the 
latter  change  being  the  more  common.  In  normal  blood  the  protoplasm  of 
the  leucocytes  is  stained  a  pale  yellow  and  the  -nuclei  remain  almost 
colorless. 

I  Antibacterial  Action  of  the  Blood. — According  to  Halliburton,  ^  "the 
power  of  the  blood  to  destroy  bacteria  was  first  discovered  when  an  effort 
was  made  to  grow  various  kinds  of  bacteria  in  it;  the  blood  was  believed 
to  be  a  suitable  soil  for  this  purpose,  but  it_  was  found  to  have  the  opposite 
effect  in  many  instances.  The  chemical  characters  of  the  substances  which 
kill  the  bacteria  are  not  fully  known.  Evidence  appears  to  favor  the  leuco- 
cytes as  the  origin  of  this  bactericidal  substance.  These  substances  are 
called  alexins,  but  the  more  usual  name  now  applied  to  them  is  that  of 
bacteriolysins.  The  bactericidal  power  of  the  blood  is  closely  related  to  its 
alkalinity.  Increase  of  alkalinity  means  increase  of  bactericidal  power. 
Alkalinity  is  probably  beneficial,  because  it  favors  those  oxidative  processes 
in  the  cells  of  the  body  which  are  so  essential  for  the  maintenance  of  healthy 
life.  Normal  blood  possesses  a  certain  amount  of  substances  which  are 
inimical  to  the  life  of  bacteria.  When  a  person  gets  run  down  there  is  a 
diminution  in  the  bactericidal  power  of  his  blood.  However,  a  perfectly 
healthy  person  has  not  an  unlimited  supply  of  bacteriolysin,  and,  if  the  bac- 
teria are  sufficiently  numerous,  he  will  fall  a  victim  to  the  disease  which 
they  produce.  In  the  struggle  he  will  form  more  and  more  bacteriolysin, 
and  if  he  gets  well,  it  means  that  the  bacteria  are  vanquished,  and  his  blood 


^  Wien.  klin.  Wochenschr.,  1897,  vol.  x. 

'  Paper  read  before  the  British  Association  for  the  Advancement  of  Science. 


THE  BLOOD.  689 

remains  rich  in  the  particular  bacteriolysin  he  has  produced,  and  so  will 
render  him  immune  to  further  attacks  from  that  particular  species  of  bac- 
terium. Every  bacterium  seems  to  cause  the  development  of  a  specific 
bacteriolysin.  Immunity  can  more  conveniently  be  produced  gradually  in 
animals,  and  this  applies,  not  only  to  the  bacteria,  but  also  to  the  toxins 
they  form.^* 

The  Blood  in  Fever. — There  is  a  decided  reduction  in  the  number  of 
red  cells  during  fever.  "Whether  the  fever  destroys  the  red  cells  or  causes 
them  to  be  unequally  distributed  in  the  body  is  the  question.  Maragliano 
demonstrated  a  contraction  of  arterioles  during  the  height  of  a  febrile 
process,  followed  by  dilatation  during  defervescence.  He  was  able  to  verify 
these  results  by  noting  the  effect  of  antipyretics  (Ewing). 

Salkowski  demonstrated  an  excess  of  potassium  in  the  blood  during 
fever,  thus  favoring  the  view  that  the  red  cells  are  destroyed.  Senator, 
von  Jaksch,  and  others  have  shown  that  febrile  processes  are  regularly 
marked  by  diminished  alkalescence  of  the  blood.  When  diphtheria  anti- 
toxin is  injected,  the  alkalinity  of  the  blood  is  increased  for  about  twenty- 
four  hours. 

The  progressive  loss  of  albumin  is  probably  associated  with  every  fever, 
but  occurs  in  a  marked  degree  when  the  fever  is  of  an  infectious  origin. 
Diminished  resistance  of  the  red  cells  occurs  in  the  majority  of  fevers  and 
depends  on  a  variety  of  factors.  Variations  in  alkalinity  are  frequent  and 
considerable  in  fever,  but  are  not  proportional  to  either  the  toxicity  or  to 
the  height  of  the  temperature  (according  to  Ewing). 

The  question  is.  Why  do  almost  all  micro-organisms  which  are  harmful 
to  the  body  raise  its  temperature  ?  and  the  suggestion  has  been  made  that  the 
rise  of  temperature  is  a  defensive  mechanism,  or,  in  other  words,  pyrexia 
is  like  phagocytosis  or  chemiotaxis,  in  some  way  harmful  to  the  fever- 
producing  micro-organisms  or  their  toxins.  It  does  not  follow  from 
this  view  that  the  higher  the  temperature  of  the  body  the  better  the 
prognosis,  for  the  higher  temperature  might  be  taken  to  indicate  that  the 
dose  of  infection  was  very  severe,  and  that,  therefore,  the  body  did  all  it 
could  to  resist  the  invasion;  nor,  on  the  other  hand,  would  it  follow  that 
if  the  temperature  did  not  rise  much,  the  dose  of  infection  was  slight,  for 
it  might  be  that  the  body  was  feeble  and  had  but  little  power  of  raising 
its  temperature,  and  therefore  defending  itself. 

It  is  generally  believed,  and  in  all  probability  correctly,  that  many 
cases  of  typhoid  fever  are  benefited  by  cold  sponging  or  by  a  cool  bath. 
Many  have  hastily  concluded  that  the  bath  does  good  because  it  lowers  the 
temperature.  But  this  is  probably  incorrect.  In  the  first  place  we  must 
remember  that  the  cold  sponging  or  bath  does  more  than  lower  the  tem- 
perature; it  diminishes  the  delirium,  the  tremor,  and  the  prostration.  In 
any  of  these  ways  it  would  do  good.    But,  further,  Eoque  and  Weil  claim 

44 


690  DISEASES  OF  THE  BLOOD. 

to  have  shown  that  "in  typhoid  fever  left  to  itself  the  toxic  products  manu- 
factured by  the  bacillus  and  organism  are  eliminated  in  part  during  the 
illness.  The  urotoxic  coefficient  is  double  the  normal^  but  this  elimination 
is  incomplete  and  is  only  completed  during  convalescence,  for  the  h5^3er- 
toxicity  continues  for  four  or  five  weeks  after  the  cessation  of  the  fever. 
In  typhoid  treated  by  cold  baths,  the  elimination  of  toxic  products  is  -enor- 
mous during  the  illness.  The  hypertoxicity  diminishes  as  the  general  symp- 
toms mend  and  as  the  temperature  falls,  so  that  when  the  period  of  pyrexia 
and  convalescence  sets  in  the  elimination  of  toxins  has  ceased.''  •  So  we 
learn  that  it  is  by  no  means  certain  that  in  typhoid  fever  the  benefit  of  cold 
baths  is  due  to  their  antipyretic  influence  alone,  but  also  to  the  elimination 
of  toxins.  We  see  that  clinical  medicine  affords  no  evidence  that  anti- 
pyretics are  useful  in  fever. 


CHAPTER  11. 
Diseases  of  the  blood. 

Anui;mia. 

A  DEFICIENCY  ill  tlio  number  of  red  blood-cells  or  of  the  haemoglobin 
is  known  as  anaemia.  As  a  rule  there  are  two  distinct  forms :  first,  con- 
genital; second,  acquired. 

Congenital  Form. — The  foetus  in  utero  is  frequently  anaemic  owing  to 
the  inherited  disease  of  its  mother.  Such  diseases  are  blood  disorders  like 
syphilis,  or  where  a  general  devitalization  occurs,  as  seen  in  tuberculosis. 
If  the  mother  while  pregnant  passes  through  a  severe  form  of  diphtheria, 
typhoid  fever,  or  any  other  infectious  disease,  it  may  result  in  anaemia  of 
her  offspring. 

Malarial  infection  of  the  mother  may  also  result  in  an  anaemia  of  the 
baby.  A  severe  haemorrhage  due  to  an  operation  on  the  mother  during  the 
last  period  of  her  pregnancy  may  cause  an  ansemia  of  the  baby. 

Acquired  Form. — This  form  is  due  to  either  an. infection  of  the  baby 
or  to  toxic  conditions  acquired  after  birth  and  independent  of  the  mother. 
Most  cases  of  acquired  anaemia  seen  by  me  are  the  direct  result  of  mal- 
nutrition. I  have  referred  in  detail  to  this  condition  in  the  chapter  on 
"Scurvy"  and  "Eachitis." 

Splenic  Anemia  (Splenomegalic  Cirrhosis  of  Liver; 
Banti's  Disease). 

The  characteristic  features  of  this  disease  consist  in  progressive  enlarge- 
ment of  the  spleen,  later  in  the  disease  cirrhosis  of  the  liver  with  ascites, 
and  jaundice. 

Etiolo^. — An  intoxication  is  probably  the  cause  of  this  condition. 
Whether  it  is  gastric  or  intestinal  is  not  easily  determined. 

Pathology. — There  is  a  hyperplasia  and  fibrosis  of  the  spleen,  secondary 
anaemia,  and  cirrhosis  of  the  liver  as  a  terminal  development  in  some  cases. 

Symptoms. — As  a  result  of  hemorrhages,  such  as  hsmatemesis  or  in- 
testinal bleeding,  there  is  a  secondary  anaemia.  Bleeding  may  not  only  be 
confined  to  the  stomach  and  bowels,  but  it  may  also  be  due  to  gastric  erosions 
or  varicose  veins  in  the  oesophagus.  In  some  cases  the  gums  will  bleed. 
There  is  usually  jaundice  because  of  the  cirrhosis  of  the  liver,  associated 
therewith  anorexia.  Constipation  or  diarrhoea  may  be  present.  The 
examination  of  the  blood  shows  nothing  definite  excepting  a  leukopaenia  and 
a  relative  lymphocytosis.  There  is  also  a  hsemic  murmur  which  is  systolic. 
The  slightest  exertion  will  be  followed  by  tachycardia.  The  urine  may  con- 
tain albumin,  but  no  casts,  although  blood-  and  pus-  cells  have  been  found. 
The  temperature  is  rarely  above  100°  in  the  evening,  and  is  usually  about 
99°  in  the  morning.  The  course  of  the  disease  is  chronic,  the  treatment 
purely  symptomatic. 

(691) 


692  DISEASES    OF    THE    BLOOi). 

Secondaet  Anemia, 

Canses. — Toxic  influences  frequently  destroy  the  blood  corpuscles  and 
also  the  hsemoglobin,  hence  angemia  results.  When  haemorrhage  takes  place 
then  anaemia  frequently  follows.  Malaria  and  whooping-cough  seem  to 
affect  children  more  than  adults.  Other  diseases,  such  as  rheumatism  and 
endocarditis,  in  fact,  most  of  the  acute  infectious  diseases,  cause  anaemia. 
Improper  hygiene,  and  more  frequently  improper  food,  should  not  be  over- 
looked as  causative  factors. 

Symptoms. — A  pale  white  skin  and  waxy  appearance  of  the  nails  is 
the  usual  clinical  picture.  Children  do  not  appear  bright.  They  take  no 
interest  in  their  surroundings,  and  do  not  wish  to  play.  Loss  of  appetite 
and  tendency  to  constipation  frequently  exist. 

Diagnosis. — This  is  usually  determined  by  the  condition  of  the  blood. 

Prognosis. — The  origin  of  the  angemia  should  be  the  guide  in  deter- 
mining the  outcome  of  this  condition.  Great  care  should  be  used  in  ven- 
turing an  opinion,  unless  we  are  sure  of  the  origin  and  can  remove  the  cause 
of  same. 

Treatment. — Fresh  air,  food  (chiefly  proteids),  and  restoratives,  such 
as  codliver-oil,  lipanin,  iron.  Fowler's  solution,  and  malt  preparations,  are 
indicated.    Wine  or  champagne  is  sometimes  valuable. 

Pernicious  Anemia. 

This  rare  condition  is  sometimes  seen  in  children. 

Etiology. — It  may  follow  simple  anaemia  so  that  it  would  appear  as 
the  result  of  a  continuation  of  malnutrition.  Many  theories  are  offered. 
Tape-worm,  syphilis,  and  rachitis  are  believed  to  be  the  factors  causing  this 
condition. 

Pathology. — Hunter  first  reported  the  presence  of  a  deposit  of  iron  in 
the  hepatic  cells.  There  is  also  an  angemia  of  the  internal  organs.  Soine- 
times  capillary  haemorrhages  are  seen  in  the  various  organs.  Fatty  degen- 
eration is  also  described  as  a  frequent  pathological  finding. 

General  Symptoms. — These  are  the  same  as  previously  described  in  the 
article  on  anaemia,  although  all  symptoms  are  of  a  more  severe  type.  '  Epi- 
staxis,  in  addition  to  local  purpuric  spots,  denotes  the  tendency  to  htemor- 
rhages.  An  interference  of  the  return  circulation  to  the  heart  is  manifested 
by  oedema  of  the  feet  and  ankles.  The  urine  contains  neither  albumin  nor 
casts. 

Special  Symptoms. — The  blood  will  furnish  the  real  means  of  diag- 
nosis. The  haemoglobin  may  sometimes  be  as  low  as  20  to  30  per  cent. 
The  erythrocytes  are  reduced  in  number;  2,000,000  is  a  fair  average  red 
blood  count  in  this  condition,  although  Lenhartz^  refers  to  a  reduction  of 


'Lenhartz — "Clinical  Microscopy,"  page  156.     F.  A.  Davis  Co.,  1904. 


IM.ATE  XXXII 


A. — Progeessive  Pernicious  An.emia.  The  ease  ended  fatally  in  six 
Aveeks;  cause  unknown;  possibly  in  connection  with  typhoid  fever.  Ehrlich's 
triacid  stain.     Zeiss  ocular   1,  oil   immersion  Vi2-     o,  normal   erythrocytes; 

b,  megalocytes;    c,    microcytes;    d,    marked    poikilocytosis;    e,    megaloblast; 
/,  polynuclear  neutrophilic  leucocyte.      (I>enhartz-Brooks. ) 

B. — LiENAL  (Splenic)  Leukemia,  a,  noi-mal  erythrocyte:  /).  nucleated 
erythrocyte,  nucleus  eccentrically  situated;  c,  polyniiclcar  neutropliilic  leuco- 
cytes; rZ,  eosinophilic  (myelo)  cell.  The  eosino]ihilic  cell  at  the  top  has 
been  ruptured  and  the  granula  dispersed.  Two  small  greenish-blue  nuclei, 
perhaps  small  lymphocytes.      (Lenhartz-Brooks. ) 

C. — LiENAL  (Splenic)  Leuk/EMTa.  a1.  megaloblast;  a.  normal  erythro- 
cyte; a2,  megaloblast.  with  anremic  degeneration;   ft.  polynuclear  leucocytes; 

c,  "marrow  cells"   (myelocytes);   d.  large  lym])hocyte.      (Lenhartz-Brooks.) 

7). — AcT^TE  LErK.T;AriA.  This  picture  is  made  from  two  different,  rapidly 
fatal,  clinically  similar  cases.  The  upper  portion  is  stained  with  Ehrlich's 
stain  with  eosin-hematoxylin;  the  lower  portion  is  stained  with  the  Plehn- 
Chenzinsky's  stain.      (Lenhartz-Brooks.) 


LEUKEMIA.  693 

erythrocytes  as  low  as  400;,000  to   800,000.     There  is  also  an  enormous 
poikilocytosis. 

In  this  disease  there  is  a  greater  reduction  in  the  number  of  red  blood 
cells  (oligocythemia)   than  in  any  other  disease. 

LEUKiEMIA    (LeUKOCYTH^MIA). 

In  this  condition  we  have  a  reduction  of  the  red  corpuscles  and  a  cor- 
responding increase  in  the  white  blood  cells. 

Cellular  forms  called  lymphocytes  not  otherwise  found  in  health  are 
present  in  the  blood.  Virchow  calls  this  condition  "white  blood."  Ehrlich 
calls  it  a  leucocytosis  of  a  chronic  type. 

Etiology. — This  is  unknown.  Some  authors,  Roux  and  Lowit,  describe 
asporozoa  in  the  blood  as  well  as  in  the  leucocytes  and  in  the  spleen.  Other 
writers  believe  that  there  is  a  predisposition  in  syphilitic  and  rachitic  chil- 
dren. Unsanitary  surroundings  and  injury  to  the  spleen  are  decided  etio- 
logical factors. 

The  following  classification  is  given  by  Ehrlich: — 

(a)  Lymphatic  forms. 

(b)  Myelogenous  and  splenic  forms. 

Lymphatic  Form. — When  the  colorless  corpuscles  are  as  large  as  a 
normal  erythrocyte  then  an  involvement  of  the  glandular  system  can  be 
diagnosticated. 

Myelogenous  and  Splenic  Forms. — If  large  cells  appear  then  bone- 
marrow  and  the  spleen  evidently  participate.  When  large  mononucleated 
leucocytes  are  found  then  the  bone-marrow  is  probably  involved.  If,  in  the 
field  of  the  microscope,  three  to  five  or  more  cells  filled  Math  strongly  re- 
fractive spheroid  granules  are  found,  the  splenic  involvement  should  be 
suspected. 

Pathology. — The  lesions  are  confined  to  the  bone-marrow,  lymphatic 
glands,  and  spleen.  The  spleen  is  enormously  enlarged,  sometimes  filling 
half  of  the  abdominal  cavity.  Sometimes  it  is  soft,  and  at  other  times  very 
hard  on  palpation.  It  has  a  dark  red  color.  In  the  lymphatic  form  any 
or  all  of  the  external  glands  of  the  body  may  be  affected ;  thus  the  cervical, 
maxillary,  bronchial,  mesenteric,  or  inguinal  glands  may  be  involved. 
There  is  a  simple  hyperplasia  found  in  the  glands.  The  liver  is  usually 
enlarged  from  an  infiltration  with  lymphoid  tissue.  The  lymphoid  tissue 
in  the  tonsils  and  the  thymus  gland  have  the  same  changes.  Haemorrhages 
are  not  infrequent. 

Symptoms  and  Diagnosis.^The  disease  is  usually  ushered  in  by  a  severe 
hemorrhage,  after  which  proround  anaemia  and  a  general  weakness  are  noted. 
The  spleen  is  alwa3^s  enlarged  and  the  lymphatic  glands  are  palpable.  The 
glands  are  movable,  but  never  tender  on  palpation.  The  liver  is  usually 
enlarged.    In  the  beginning  there  is  little  or  no  fever,  although  later  in  the 


694  DISEASES    OF    THE    BLOOD. 

disease  the  temperature  may  rise  as  high  as  103°  F,  Sometimes  from  in- 
volvement of  the  liver  there  will  be  dropsy  of  the  feet  or  a  general  anasarca. 
Haemorrhages  from  the  nose,  mouth,  stomach,  and  bowels  frequently  com- 
plicate this  condition.     From  the  loss  of  blood  fainting  spells  may  occur. 

The  Blood. — The  characteristic  feature  is  an  increase  in  the  number 
of  leucocytes.  The  normal  ratio  between  the  red  and  white  corpuscles  varies 
between  1  to  500  and  1  to  1000.  In  leuksemia  the  ratio  is  so  altered  that 
we  may  have  one  colorless  corpuscle  to  twenty,  or  even  to  five,  red  corpus- 
cles.    Some  authors  report  a  ratio  of  one  red  to  two  white  corpuscles. 

The  eosinophiles  are  frequently  increased  many  times  their  normal 
number.  A  characteristic  feature  is  the  presence  of  large  and  small  mono- 
nuclear lymphocytes.  Ehrlich  describes  a  large  mononuclear  nutrophilic 
staining  cell  which  normally  exists  in  the  bone-marrow,  and  is  found  in  the 
myelogonous  form  of  leukaemia.    It  is  called  the  myelocyte. 

Treatment. — The  nutrition  of  the  child  must  be  carefully  considered. 
Albumin  and  the  cereals  should  form  the  main  portion  of  the  food.  All 
vegetables  should  be  ordered.  If  the  child  can  be  taken  out  of  doors,  then 
the  same  should  be  insisted  upon.  Strict  attention  to  hygienic  details  will 
greatly  assist  in  modifying  this  condition. 

Medication. — Iron,  arsenic,  in  the  form  of  Fowler's  solution,  cod- 
liver-oil;  and  malt  extracts  should  be  given.  If  there  is  anorexia  then 
strychnia  or  nux  vomica  should  be  given. 

PSEUDO-LEUK^MIC    An^MIA   OF    TnFANCT    (An^MIA   INFANTUM 

Pseudo-Leuk^mica)  . 

Von  Jaksch  was  the  first  to  describe  this  disease  in  1889.  It  is  an 
infantile  anaemia  characterized  by  the  following  conditions : — 

1.  There  is  a  marked  enlargement  of  the  spleen. 

2.  A  slight  enlargement  of  the  liver  and  the  lymph  nodes. 

3.  A  marked  reduction  in  the  number  of  red  corpuscles. 

It  is  usually  a  secondary  anaemia  rather  than  a  primary  disease. 

Etiology. — The  disease  is  usually  found  in  infants  and  children  be- 
tween 6  months  and  4  years  of  age. 

Monti  and  Berggrun  collected  16  cases  in  1893.  Pickets,  congenital 
syphilis,  chronic  intestinal  catarrh,  and  tuberculosis  were  found  in  cases 
collected  by  Fischl. 

Pathological  Anatomy. — The  spleen  is  enlarged  and  rather  firm. 
Histologically,  the  changes  are  those  of  simple  hyperplasia  of  all  elements, 
while  the  sinuses  contain  no  excessive  number  of  leucocytes.  Baginsky 
found  many  eosinophile  cells  in  the  spleen.  The  changes  in  the  viscera  are 
described  by  Von  Jaksch,  Eppinger,  Luzet,  Baginsky,  Audeoud,  and 
Rotch. 


CHLOROSIS.  695 

The  marrow,  according  to  Luzet,  is  diffusely  reddened  and  moist  and 
shows  evidence  of  excessive  multiplication  of  the  red  cells. 

The  Blood. — Leucocytosis  is  an  important  symptom.  The  white  blood 
cells  number  between  20,000  and  50,000.  Other  cases  (Baginsky)  between 
40,000  and  122,000. 

According  to  Monti,  the  proportion  of  white  cells  to  the  red  may  be 
as  1  to  100  or  1  to  15. 

Symptoms. — After  a  prolonged  gastro-intestinal  disease  an  infant  will 
appear  very  anemic.  Fever  is  not  usually  present.  When  fever  is  pres- 
ent the  cause  of  the  same  will  usually  be  found  other  than  in  the  spleen. 
Icterus  is  sometimes  present. 

There  is  a  decided  loss  of  appetite  and  the  bowels  move  sluggishly. 
The  skin  has  a  yellowish  color  and  is  intensely  anemic.  The  abdomen 
appears  distended.  The  liver  is  slightly  enlarged.  The  lymph  glands  are 
palpable.  The  spleen  is  very  much  enlarged  and  occupies  the  left  hypo- 
chondrium,  reaching  at  times  to  the  crest  of  the  ilium. 

Prognosis. — ^The  prognosis  is  poor,  although  recovery  does  take  place 
in  some  instances.  A  case  of  this  kind  seen  by  me  has  shown  marked  im- 
provement under  anti-rachitic  and  restorative  treatment. 

Treatment. — ^Tonic  doses  of  iron,  quinine,  and  strychnine  served  me 
well.  Codliver-oil  and  the  glycerophosphites  of  lime  and  soda  are  indi- 
cated. Phosphorus  has  been  recommended  by  some.  The  bowels  must  be 
thoroughly  cleansed,  and  the  general  peristalsis  stimulated.  Nux  vomica, 
in  1-minim  doses  three  times  a  day,  when  anorexia  and  gastric  atony  are 
present.  Fresh  air  and  general  hygienic  management,  in  addition  to  a 
supporting  diet,  will  do  more  toward  building  up  and  restoring  the  system 
than  all  medication  combined. 

Chlorosis. 

Chlorosis,  sometimes  called  chloroanasmia,  occurs  in  girls  about  the 
period  of  puberty.  There  is  extreme  pallor  of  the  mucous  membrane,  pale 
and  greenish  tint  to  the  skin,  and  a  pearly  eye.  Associated  therewith  is 
extreme  lassitude,  a  tired  feeling,  and  either  suppression  or  irregularity 
of  menstruation.  There  is  a  venous  hum  which  can  be  plainly  heard  in  the 
vessels  of  the  neck.  On  the  slightest  exertion  there  will  be  dyspnoea,  pal- 
pitation, and  dizziness.  As  a  rule,  such  children  do  not  emaciate;  they  are 
rather  well  nourished.  Owing  to  a  freaky  appetite,  the  bowels  are  irregular 
and  usually  constipated.  The  urine  frequently  contains  indican,  and  some 
observers  believe  that  the  intestinal  toxtemia  is  an  important  factor  in  the 
causation  of  this  disease. 

Etiology. — Sedentary  occupation  associated  with  lack  of  exercise,  or 
poor  hygienic  surroundings,  may  induce  this  condition.  Nervous  girls, 
susceptible  to  mental  influences,  such  as  fright  or  worr)',  are  more  prone 


696  DISEASES  OF  THE  BLOOD. 

to  the  development  of  this  condition  than  robust,  healthy  girls.  Auto- 
intoxication is  certainly  a  factor,  as  I  have  frequently  seen  chlorosis  in 
girls  suffering  with  chronic  constipation. 

Pathology. — ^Distinet  pathological  lesions  cannot  be  attributed  to  this 
condition.  In  some  cases  ulcer  of  the  stomach  is  associated,  and  this  latter 
condition  may  be  fatal. 

Symptoms. — The  appetite  is  poor  and  such  girls  invariably  crave  for 
sour  and  spiced  foods  to  stimulate  the  appetite.  Constipation  is  almost  al- 
ways present.  Headache  and  other  nervous  symptoms  are  also  present.  Such 
girls  are  very  emotional,  and  cry  and  laugh  very  easily.  They  are  very 
sensitive.  A  venous  murmur  can  usually  be  made  out  in  the  vessels  of  the 
neck.  There  is  a  blowing  systolic  murmur  which  can  be  heard  over  the 
heart  in  the  mitral  region  and  also  in  the  region  of  the  pulmonary  artery. 
Venous  thrombosis  is  most  frequently  seen  in  the  femoral  veins,  and  vari- 
cose veins  are  sometimes  seen  over  the  thighs  and  ankles.  Menstruation  is 
irregular  and  the  flow  is  scanty  or  very  profuse  and  sometimes  painful. 
There  is  a  decrease  in  the  percentage  of  hasmoglobin  and  also  a  decrease  in 
the  number  of  red  corpuscles.    The  red  cells  may  be  reduced  to  4,000,000. 

The  spleen  may  be  slightly  enlarged,  but  on  this  symptom  no  reliance 
can  be  placed.  A  puffiness  of  the  face  or  oedema  of  the  ankles  due  to  a 
sluggish  return  circulation  is  occasionally  seen. 

When  localized  areas  of  pain  are  complained  of  in  the  region  of  the 
stomach,  then  gastric  ulcer  should  be  suspected. 

Diagnosis. — Chlorosis  is  met  with  in  girls  only  at  or  about  the  period 
of  menstruation.  This  is  its  characteristic  diagnostic  feature.  Such  chil- 
dren, as  a  rule,  are  fat  and  look  well  nourished. 

Prognosis. — ^This  is  always  good,  although  the  disease  may  last  several 
years.  If  chlorosis  is  a  forerunner  of  tuberculosis  or  gastric  ulcer,  then  a 
fatal  termination  may  occur.  The  outcome  of  a  case  depends  on  heroic 
restorative  treatment. 

Treatment. — Hygienic  Treatment:  Eemove  the  child  from  its  imme- 
diate surroundings,  from  the  city  to  the  country.  If  chlorosis  occurs  in  a 
girl  living  at  a  boarding-school,  in  a  convent,  or  in  a  girl  working  in  a 
factory,  the  hygienic  conditions  demand: — 

1.  To  sleep  in  an  airy  room  with  the  windows  open  at  night. 

2.  Discontinue  working,  or  studying  if  at  school,  to  procure  mental 
rest. 

3.  Change  the  entire  mode  of  living,  so  that  there  is  neither  care  nor 
worry  for  the  chlorotic  girl. 

Exercise. — Gentle  exercise,  walking,  swimming,  the  lighter  exercises  of 
physical  culture  followed  by  a  shower-bath  and  massage  are  valuable.  Fric- 
tion with  a  coarse  towel  after  the  daily  sponge  bath  is  useful  to  stimulate 
the  circulation.    Reading  or  sewing  at  night  must  be  forbidden. 


CHLOROSIS.  697 


Nutrition. — To  stimulate  metabolism  nothing  equals  food.  Proteins 
in  the  form  of  milk,  meat,  eggs,  cereals,  cream,  butter,  and  clieese  should 
be  liberally  given.  All  fresh  fruits  may  be  allowed.  Regularity  in  feeding 
must  be  demanded,  although  a  drink  of  milk,  buttermilk,  cocoa,  or  zoolak 
may  be  taken  between  meals. 


Fif.    226. — Blood  from  a  Case  of  Chlorosis.     Girl   16  years  of  age.     Red  cells 
appear  pale   (achromia)    and  vary  considerably  in  size.      (Original.) 

Medicinal  Treatment. — Soluble  preparations  of  iron,  such  as  ovoferrin 
or  peptomangan,  may  be  given  in  teaspoonful  doses  after  each  meal.  Arsenic 
in  the  form  of  Fowler's  solution  or  arsenious  acid  may  be  combined  with 
the  iron.  The  arseniated  hgemaboloids  have  been  tried  by  me  with  good 
result.  Maltine  with  or  without  hypophosphites  may  be  tried  three  times  a 
day.  Codliver-oil,  morrholine,  or  lipanin  may  be  tried  in  teaspoonful  doses 
three  tim.es  a  day  given  after  meals.  The  sun  bath  or  the  electric  light 
bath  may  be  tried  in  conjunction  with  the  above-described  treatment. 


CHAPTEE  III. 

ACUTE  RHEUMATISM  (POLYARTHRITIS). 

This  disease  is  sometimes  known  as  rheumatic  fever,  also  as  inflam- 
matory rheumatism.  It  is  an  acute,  infectious,  but  non-contagious  disease. 
The  infection  is  characterized  by  an  inflammation  which  localizes  in  the 
joints,  and  travels  from  joint  to  joint,  evidently  through  the  circulation. 
The  most  frequent  complication  is  endocarditis. 

Etiology. — The  specific  factor  is  evidently  a  micro-organism.  A  great 
many  observers  have  studied  this  subject,  among  them.  Ley  den,  Sahli, 
Achalme,  Eiva,  Triboubet,  Coyon,  Singer,  Jaccoud,  and  many  others.  A 
bacillus  described  as  an  anaerobic,  with  more  or  less  motility,  similar  to  the 
anthrax  bacillus,  has  been  described  by  Achalme.  This  bacillus,  when  in- 
jected into  animals,  has  reproduced  symptoms  resembling  rheumatism. 
Thus  this  observer  believes  he  has  found  the  specific  agent  causing  this 
disease. 

Other  causes  have  been  described  as  the  result  of  defective  assimila- 
tion, which  produces  lactic  acid  or  combinations  of  it.  Another  theory 
is  the  so-called  nervous  theory,  in  which  the  nerve  centers  are  primarily 
affected  by  cold,  and  the  local  lesions  are  atrophic  in  character. 

This  nervous  disturbance  brings  about  hurtful  metabolism,  so  that  the 
nitrogenous  products,  instead  of  being  converted  into  urea,  are  transformed 
into  uric  acid  and  other  poisonous  products  which  cause  these  symptoms. 

Whether  or  not  heredity  bears  any  relationship  to  the  cause  of  this 
disease  may  be  considered  by  the  fact  that  in  two-thirds  of  the  cases,  dis- 
eases of  a  similar  type  can  be  traced  to  the  ancestors.  Gouty  parents 
will  usually  have  rheumatic  children.  The  disease  is  very  common  in 
children,  and  has  also  been  observed  in  nurslings. 

Eheumatism  occurs  more  often  in  the  spring  of  the  year.  When  the 
disease  has  commenced,  it  usually  lays  the  foundation  for  future  attacks; 
in  other  words,  one  attack  of  rheumatism  predisposes  to  future  attacks  of 
the  disease. 

The  tonsils  have  frequently  been  looked  upon  as  the  seat  of  entrance 
of  this  disease;  thus  acute  tonsillitis  has  frequently  been  followed  by  acute 
articular  rheumatism.  In  the  same  manner  endocarditis  has  frequently 
followed  an  attack  of  tonsillitis.  It  is  therefore  safe  to  assume  that  the 
rspecific  entrance  of  an  infection  can  originate  in  a  diseased  tonsil. 

Packard  has  described  a  series  of  cases  of  endocardial  inflammation 
(698) 


ACUTE    RHEUMATISM.  699. 

following  tonsillitis.  He  regards  a  serous  inflammation  as  due  to  the  germs 
or  other  toxins  entering  the  circulation  through  inflamed  tonsils. 

Bacteriology. — Triboulet  and  Coyon^  give  the  results  of  their  bac- 
teriologic  examinations  in  11  cases  of  acute  articular  rheumatism.  They 
discovered  in  all  these  cases  a  diplococcus  or  diplobacillus  which  they  state 
cannot  be  well  described  as  to  its  cultural  peculiarities,  as  its  growth  is  so 
irregular. 

The  organism  exhibits  great  plesiomorphism  and  resembles  most  closely 
in  character  the  diplococcus  pneumoniae,  but  differs  from  it  in  that  it  can 
be  kept  alive  for  a  considerable  length  of  time,  and  that  it  is  not  patho- 
genic for  mice.  The  organism  is  extremely  pathogenic  for  rabbits,  and 
the  authors  give  a  detailed  account  of  its  effects  on  a  rabbit.  The  animal 
died  twenty  days  after  intravenous  inoculation.  Death  was  due  to  heart 
failure  resulting  from  an  absolute  mitral  insufficiency.  During  life  there 
was  an  oscillatory  temperature.  The  autopsy  showed  fresh  pleuritis  and 
pericarditis,  and  an  acute  vegetative  endocarditis  with  tremendous  masses 
of  vegetations  on  the  mitral  valve.  The  vegetations  microscopically  showed 
many  diplobacilli  similar  to  those  originally  inoculated,  and  cultures  from 
the  organs  also  showed  it.  Other  rabbits  inoculated  with  smaller  doses  from 
other  cases  showed  irregular  fever,  disturbances  of  the  heart,  and  pleurisy, 
but  did  not  die. 

Symptoms. — The  symptoms  are  entirely  different  from  those  met  with 
in  adults.  The  fever  is  not  so  high,  usually  between  100°  and  102°  F. 
The  swelling  of  the  joints  is  moderate,  and  there  is  not  the  redness  and 
inflammation  visible  to  the  eye  as  we  see  it  in  adults.  The  pains  are  not 
severe  in  all  cases,  and  there  are  less  joints  involved  as  a  rule  than  we 
find  in  adults.  We  therefore  meet  with  a  great  many  cases  of  rheumatism 
that  walk  around  suffering  slight  pains.  Sometimes  the  lower  extremities 
are  affected,  at  other  times  the  disease  is  limited  to  the  upper  extremities. 
A  child  may  walk  apparently  lame  or  an  infant  may  cry  when  put  on  its 
feet,  Jacobi  years  ago  directed  the  attention  of  the  profession  to  the 
necessity  of  carefully  watching  every  case  of  so-called  "growing  pains.'' 
He  believed,  and  correctly  so,  that  the  majority  of  these  cases  were  in 
reality  rheumatism.  The  most  frequent  symptoms  are  vomiting,  fever,  gen- 
eral malaise,  anorexia,  in  addition  to  multiple  arthropathy. 

Rheumatism  a  Seauela  to  Tonsillitis. — ^That  rheumatism  is  irequently 
a  sequel  to  tonsillitis  has  been  noted  by  many  observers.  Packard,  of  Phila- 
delphia, has  reported  a  scries  of  cases  in  which  the  throat  was  first  affected 
and  later  heart  disease  was  distinctly  manifested.  Emil  Mayer,  of  New 
York  City,  has  also  reported  a  series  of  cases  in  which  the  tonsils  were  the 


Comptes  Rendus  de  la  Society  de  Biologie,  February  4,  1898. 


JOO  DISEASES    OF    THE    BLOOD. 

portals  of  infection.  This  is  certainly  not  a  theory  when  we  study  the 
primarj'  infection  and  follow  it  up  with  its  secondary  result. 

Sir  Willoughby  Wade^  says,  in  relationship  between  tonsillitis  and 
rheumatic  fever,  he  believes  that  tonsillitis  is  a  primary  infective  disease 
of  the  lacunas;  rheumatic  fever  a  secondary  disease  arising  from  the 
absorption  of  microbes  or  their  products  into  the  system.  Knowing  this 
to  be  a  factor,  it  would  only  seem  proper  to  treat  every  tonsillitis  as  vigor- 
ously as  possible. 

Acute  Contagious  Articular  Rheumatism. — G.  B.  AUari  reports  3 
cases  which  were  characterized  by  contagiousness  and  at  the  beginning  of 
tlie  disorder  with  angina  of  the  throat.  In  the  fourth  case  the  angina  re- 
appeared with  every  reappearance  of  exacerbation  of  the  articular  symptoms. 
Bacteriological  investigations  of  the  exudate  on  the  tonsils  showed  in  each 
case  a  streptodiplococcus  which  was  almost  identical  in  structure  and  be- 
havior with  that  found  by  Mayer  in  the  same  affection.  Animals  inoculated 
with  this  micro-organism  developed  lesions  in  the  joints. 

Suhcutaneous  Tendinous  Nodules. — Barlow  and  Warner  described  this 
manifestation  of  rheumatism  in  1881  as  oval  semi-transparent  fibrous  bodies 
like  boiled  sago  grains.  They  are  most  frequently  met  with  at  the  back  of 
the  elbow,  over  the  malleoli,  and  at  the  margin  of  the  patella.  Occasionally 
on  the  extensior  tendons  of  the  hands,  fingers,  and  toes,  or  over  the  spinous 
processes  of  the  vertebrag.  They  are  composed  of  fibrin,  cells,  and  fibrous 
tissue.  They  vary  in  size  from  a  pin-head  to  a  small  bean,  though  some- 
times beiiig  as  large  as  an  almond.  They  may  remain  for  months,  although 
they  frequently  disappear  in  a  few  weeks.  Cheadle  states  that  they  can  be 
seen  if  the  skin  is  tightly  drawn.  Cheadle  has  also  shown  the  intimate  rela- 
tionship between  erythema  and  rheumatism. 

Purpura. — This  is  frequently  met  with  in  the  course  of  rheumatism. 
It  is  a  rash  of  a  deep  purplish  hue  and  is  most  probably  a  result  of  rheu- 
matism. 

Complications. — The  most  frequent  form  of  complication  is  endocar- 
ditis. Fully  75  per  cent,  of  my  cases  met  with  in  a  large  outdoor  practice 
showed  this  form  of  complication.  This  complication  has  frequently  been 
the  first  symptom  that  led  to  the  discovery  that  our  patient  had  rheuma- 
tism. 

Pericarditis  is  rarely  seen  in  children  under  7  years  of  age.  It  is 
usually  associated  with  endocarditis. 

Pleurisy,  peritonitis,  or  meningitis  may  complicate  rheumatism. 
Chorea  frequently  associates  itself  with  rheumatism,  so  that  a  great  many 
authors  believe  that  there  is  an  intimate  relationship  between  rheumatism 
and  chorea. 


•  British  Medical  Journal,  1898. 


ACUTE    RHEUMATISM.  701 

Holt  states  that  in  a  series  of  cases  of  chorea  observed  by  him,  56 
per  cent,  gave  evidence  of  the  rheumatic  diathesis. 

Prognosis  and  Course. — The  course  of  rheumatism  depends  on  the 
treatment.  i*ains  in  tlic  joints  sliould  never  be  regarded  as  a  trivial 
matter.  How  frequently  do  we  see  a  child  suffering  with  what  the  mother 
calls  "growing  pains,"  and  a  few  weeks  or  months  later  we  note  shortness 
of  breath  due  to  heart  trouble,  usually  endocarditis.  It  is  better  to  put  a 
child  to  bed  than  to  run  risks  of  such  a  serious  complication.  The  prog- 
nosis depends  on  the  care  bestowed,  although  we  know  that  this  disease  has 
a  tendency  to  assume  a  chronic  course.  Plowever,  a  case  with  proper  treat- 
ment should  recover  entirely.  The  inflammatory  stage  lasts  from  ten  days 
to  two  weeks.  Cases  of  inflammatory  rheumatism  complicating  scarlet 
fever  or  diphtheria  lasting  between  three  and  eight  weeks  have  been  seen 
by  me  during  my  hospital  service. 

Kheumatism  in  children  assumes  the  course  of  a  general  infectious 
malady.  The  intensity  of  cardiac  complications  cannot  be  approximated 
by  the  intensity  or  mildness  of  articular  manifestations.  Many  authorities 
state  that  the  percentage  of  cardiac  complications  is  between  81  and  87 
per  cent. 

Lethal  termination  will  frequently  show  pericarditis,  hence  the  im- 
portant deduction  is  to  prevent  such  complications,  if  possible,  by  proper 
prophylactic  treatment. 

Treatment. — The  first  thing  to  do  is  to  put  the  child  in  bed.  The 
patient  should  be  kept  in  bed  until  every  particle  of  pain  and  fever  is  gone. 

1.  When  the  disease  is  localized  we  can  treat  the  same  and  try  to 
destroy  as  much  of  the  pathogenic  infection  as  possible. 

2.  The  important  point  would  be  to  restore  the  subnormal  condition  at 
the  time  of  the  invasion  of  these  infective  germs,  and  prevent  thereby  the 
absorption  of  the  toxins  generated  from  these  micro-organisms. 

3.  Watch  for  possible  complications.  While  it  is  true  that  we  can 
limit  by  local  treatment  the  spread  of  active  infective  processes,  on  the 
other  hand,  when  the  body  is  weakened  from  anieraia,  or  from  other  de- 
pressing influences,  this  infection  will  spread  in  spite  of  the  most  vigorous 
local  treatment. 

Eest  must  be  enjoined,  more  so  in  children  with  this  disease  than  in 
most  other  diseases.  We  must  aim  to  have  the  most  perfect  physiological 
repose.  In  this  Avay  we  have  the  longest  interval  between  the  systoles  and 
we  keep  down  the  blood  pressure. 

,  Prophylactic  Treatment. — In  trying  to  prevent  rheumatism  the  h)'- 
giene  of  the  skin  requires  careful  attention.  The  body  should  be  properly 
protected,  due  allowance  being  made  for  sudden  changes  in  the  weather. 
Too  much  clothing  means  overheating.  Perspiration  induced  thereby  in- 
vites this  disease  when  the  surface  is  suddenly  chilled.    Overheated  apart- 


702  DISEASES  OF  THE  BLOOD. 

ments  render  children  peculiarly  susceptible  to  this  disease.  Proper  ven- 
tilation, without  incurring  any  draught,  is  urgently  demanded.  Cool  or 
tepid  bathing  or  sponging  has  a  very  good  efEect  on  the  skin.  Unneces- 
sary and  useless  hardening  of  children^  by  exposing  them  to  cold  baths  in 
cold  rooms,  without  proper  protection,  will  certainly  invite  this  disease. 

Dietetic  Treatment. — Milk  and  milk  foods;  cereials  and  fruits,  espe- 
cially acid  fruits ;  broths  and  all  soups  made  from  meat  are  indicated.  For 
thirst,  buttermilk,  and  all  fermented  milks,  seltzer  and  milk,  alkaline  waters, 
lithia,  apollinaris,  white  rock,  lemonade,  and  orangeade. 

Medicinal  Treatment. — The  alkaline  treatment  known  as  Fuller's 
method  has  been  abandoned  many  years  ago.  The  first  thing  to  do  is  to 
cleanse  the  gastro-intestinal  tract.  A  wineglassful  or  more,  depending  on 
the  age  of  the  child,  of  citrate  of  magnesia,  repeated  every  two  hours,  until 
its  effect  is  produced.  Ehubarb  and  soda,  5-  to  10-  grain  doses,  or  calomel, 
is  valuable.  Salicylate  of  soda,  3  grains  every  three  hours,  for  a  child  3 
years  old.  Older  children  in  proportion.  This  treatment  should  be  con- 
tinued two  or  three  days,  if  the  drug  is  well  borne : — 

IJ  Natr.  salicylat 1  draelim 

Elix.  lactopeptin  2  ounces 

M.     Sig. :    One  drachm  every  three  hours  may  be  given. 

Salol  or  salophen,  in  doses  of  2  to  5  grains,  is  indicated.  Aspirin  or 
novatophan  in  doses  of  3  to  10  grains  may  be  given  every  three  hours. 
Cotton  saturated  with  the  oil  of  wintergreen  applied  over  the  affected 
joints,  the  whole  covered  with  oil-silk,  is  recommended. 

Fever. — Fever  requires  the  same  treatment  in  this  disease  as  in  all 
others.    Cold  sponging  of  the  surface  will  do  good. 

Restorative  Treatment. — ^The  profound  ansemia  caused  by  this  disease 
is  an  indication  for  early  restorative  treatment.  We  should  therefore  aid 
nutrition  by  giving  cream,  butter,  and,  if  tolerated,  codliver-oil,  with  or 
without  malt.  Iron  and  iodide  of  sodium  are  good  restoratives.  Fellows' 
syrup  of  the  hypophosphites  may  be  tried.  The  application  of  leeches, 
blisters,  or  sinapisms  sometimes  does  good.  Ice-bags  applied  over  inflamed 
joints  will  reduce  swelling,  remove  heat,  and  have  a  very  soothing  effect. 

An  ice-bag  applied  over  the  heart  if  endocarditis  complicates  has  served 
me  quite  well  in  some  cases.  For  the  management  of  heart  complications, 
see  chapter  on  "Heart  Diseases." 

It  is  vital  to  stimulate  the  action  of  the  kidneys.  For  this  reason  I 
have  previously  mentioned  the  alkaline  mineral  waters.  If  a  diuretic  is 
indicated  none  is  better  than  Basham's  mixture.  See  formula  in  cha|)ter 
on  "Scarlet  Fever,"  page  627. 

The  following  ointment  is  useful  applied  on  gauze  to  the  affected 
joint : — 


MUSCULAR    RHEUMATISM.  703 

B  Methyl  salicylate  1  part 

Vaseline 10  parts 

Mix. 

Apply  morning  and  evening. 

Warm  Bathing. — By  adding  sulphur  in  the  form  of  kalium  sulphuret, 
about  1  ounce  to  an  infant's  bath-tub  of  water,  and  bathing  the  affected 
joints  at  a  temperature  of  95°  to  100°  F.,  is  sometimes  very  grateful  and 
well  borne.  It  is  not  advisable  to  make  sudden  changes  in  the  local  treat- 
ment. If  ice-bags  have  been  used  and  are  well  borne,  they  should  be 
continued.  Sulphur  baths,  so  also  pine-needle  baths,  are  very  grateful  in 
the  evening,  and  sometimes  promote  sleep.  When  pains  are  very  severe, 
full  doses  of  codeine  or  chloralamid  may  be  given.  It  is  seldom  that  so 
much  truth  is  contained  in  a  single  sentence  as  in  the  following  from 
Cheadle:  "The  various  manifestations  of  rheumatism  massed  together  in 
the  case  of  adults  tend  to  become  isolated  in  the  case  of  children,  so  that 
the  whole  phenomena  are  distributed  over  years  instead  of  weeks  or  months, 
and  the  history  of  a  rheumatism  may  be  the  history  of  a  whole  childhood  " 

Muscular  Kheumatism  (Myalgia). 

This  painful  condition  is  rarely  seen  in  children.  It  is  characterized 
by  pain  when  the  muscles  affected  are  brought  into  play.  When  the  dis- 
ease affects  the  muscles  of  the  neck  it  is  called  acute  torticollis.  When  the 
intercostal  muscles  are  affected  it  is  called  pleurodynia.  When  the  lumbar 
muscles  are  affected  it  is  called  lumbago.  Peculiar  contractions  of  the 
muscles  frequently  follow  persistent  muscular  rheumatism  and  sometimes 
cause  permanent  deformity  (see  chapter  on  "Torticollis").  Infants  so 
affected  usually  cry  when  the  group  of  muscles  involved  are  moved.  There 
is  no  fever  present. 

R.  K.,  16  years  old,  was  attacked  with  a  severe  tonsillitis.  The  cervical  glands 
■were  enlarged  and  tender  on  palpation.  Creosote  inhalations  and  iinguentuni  Cred6 
rubbed  into  the  glands  of  the  neck  relieved  this  condition.  Two  days  later  after 
going  out  into  the  street  she  had  violent  muscular  pains  involving  the  back,  groin, 
and  muscles  of  the  thigh.  It  was  a  distinct  lumbago  and  a  general  myalgia.  There 
was  also  a  painful  sciatica.  With  the  aid  of  massage  and  the  internal  administra- 
tion of  5  grains  (0.3)  salophen  every  four  hours  these  pains  gradually  subsided. 
After  these  pains  left  there  were  pains  involving  the  intercostal  muscles,  so  that  we 
had  a  lumbago  followed  h\  pleurodynia.  Rest  in  bed,  warmth,  and  massage  relieved 
this  condition  permanently. 

Treatment. — Local  treatment  consisting  of  massage  aided  by  gentle 
faradic  electricity  is  very  useful.  Warm,  moist  fomentations,  such  as  flax- 
seed meal  poultices,  are  very  soothing  and  seem  to  do  good.  The  internal 
administration  of  salicylate  of  soda  has  not  seemed  to  benefit  my  cases. 
Codeine  in  Vio  to  ^/15-grain  doses,  repeated  every  two  or  three  hours,  can 


704  DISEASES    OF    THE    BLOOD. 

be  given  "imtil  the  pain  ceases.  In  some  cases  chloral  hydrate  combined 
with  bromide  of  sodium  vill  afford  relief.  Eubbing  the  affected  muscles 
with  ol.  hj'oscyamus  seems  to  relieve. 

ToKTicoLLis  (Wrt-nece:). 

This  condition  is  caused  by  the  spasm  of  one  sterno-cleido-mastoid 
muscle.  Sometimes  there  may  be  a  spasm  of  the  posterior  cervical  muscle, 
including  the  trapezius. 

Etiology. — Congenital  torticollis  is  a  rare  condition.  When  it  is 
present  it  is  due,  according  to  Whitman,  to  a  constrained  condition  in 
utero. 

More  common  "than  the  congenital  condition  is  the  acquired  torticollis. 
The  following  is  Whitman's  classification: — 

1.  The  acute.  2.  The  chronic. 

Acute  torticollis  (traumatic  torticollis)  may  be  divided  into  three 
classes : — 

(a)  "Stiff  neck/'  due  to  "cold"  or  to  rheumatism. 

(h)  Distortion  caused  by  strain  or  other  injuries. 

(c)  Distortion  due  to  irritation  of  the  peripheral  nerves  as  following 
"sore  throat/'  or  secondary,  to  enlarged  or  suppurating  cervical  glands,  and 
the  like  ("reflex  torticollis"). 

The  ordinary  stiff-neck  is  of  but  slight  importance.  The  traumatic 
wr\--neck  is  efficiently  treated  by  support.  Eeflex  torticollis  is  by  far  the 
most  important  of  the  forms  of  acute  torticollis,  and  it  is  the  usual  cause 
of  persistent  distortion. 

Chronic  Torticollis. — From  the  clinical  standpoint,  both  the  congenital 
and  the  reflex  torticollis,  after  the  acute  stage  has  passed,  are  forms  of 
chronic  torticollis;  the  class  includes  also  those  forms  in  which  the  onset 
has  not  been  accompanied  by  pain. 

Rachitic  torticollis^  usually  a  postural  or  compensatory  distortion 
caused  by  deformity  of  the  spine. 

Ocular  torticollis,  caused  by  defective  eyesight. 

Psychical  torticollis,  a  functional  or  hysterical  deformity. 

Spasmodic  torticollis,  a  convulsive  tic — rather  a  form  of  nervous  dis- 
ease than  a  simple  deformity. 

Any  irritation  of  the  spinal  accessory  nerve  or  its  branches  may  bring 
on  this  spasm.  Whitman^  gives  the  following  statistics  of  264  cases  ex- 
tending over  nineteen  years,  torticollis  from  Pott's  disease  not  being  in- 
cluded: Males,  109;  females,  155;  congenital,  32;  under  2  years,  33; 
from  2  to  10  years,  153;  over  10  years,  46;  acute  (less  than  two  months' 


*  Report  for  Hospjital  of  Ruptured  and  Crippled,  New  York. 


PURPURA.  705 

duration),  77;  chronic,  60,  of  which  number  32  had  lasted  over  two  years 
or  longer. 

Holt  believes  that  an  enlarged  cervical  lymph  gland  irritating  the 
spinal  accessory  nerve  can  bring  on  this  spasm.  He  also  mentions  malaria 
as  a  cause.  I  have  observed  similar  conditions.  In  several  of  my  cases 
the  spasm  was  present  when  malarial  infection  existed,  and  subsided  when 
quinine  was  given.  Torticollis  has  also  been  observed  by  me  after  the 
sudden  chilling  of  the  body. 

Symptoms. — The  head  is  drawn  to  the  affected  side.  If  the  trapezius 
is  affected  there  is  slight  rotation  of  the  head,  but  if  the  trapezius  is  not 
affected  the  head  is  rotated  toward  the  healthy  side. 

A  child  6  years  old  was  taken  on  an  open  ear.  She  was  in  a  healthy  condition, 
appetite  good,  bowels  regular,  ajjparently  notliing  wrong.  She  complained  of  being 
cold  and  on  the  following  day  had  a  wry-neck.  Salicylate  of  soda,  in  5-grain  doses 
three  times  a  day,  and  massage  of  the  sterno-cleido-mastoid  with  spirits  of  campiior 
seemed  to  relieve  the  pain.  The  best  r&sult  was  obtained  by  the  use  of  a  mild 
faradic  current.  The  condition  lasted  about  nine  days.  The  child  was  discharged 
cured. 

The  above  case  illustrates  the  form  commonly  described  as  rheuma-, 
iism  or  "rheumatic  torticollis." 

Treatment. — Medicinal  and  Local:  Early  treatment  means  success. 
Delayed  treatment  means  disappointment  in  most  instances.  When  specific 
causes  exist,  such  as  malaria  or  rheumatism,  they  should  be  treated  by 
specific  remedies.  In  every  case  warmth,  as  flaxseed  poulticing  and  mas- 
sage, will  do  good.  Sometimes  the  application  of  iodine  over  the  affected 
muscles  will  do  good. 

Surgical  Treatment. — Lorenz  describes  the  fine  results  attained  by  sub- 
cutaneous intentional  rupture  of  the  sterno-cleido-mastoid  muscle  to  cure 
obstinate  wry-neck  in  children.  The  subject  lies  with  a  hard  cushion  under 
the  shoulders,  the  head  and  neck  unsupported.  The  shoulder  is  drawn  down 
at  the  same  time  and  it  is  thus  possible  to  tear  the  muscle  by  gradual  de- 
hiscence, followed  by  over-correction.  Parents  accept  this  operation  much 
more  readily  than  when  the  knife  is  used,  and  the  dehiscent  fibers  heal 
under  the  intact  skin  with  little  if  any  cicatricial  formation.  The  cure  has 
been  ideal  and  permanent  in  all  his  cases. 

PURPUKA. 

Haemorrhages  into  the  skin  or  mucous  membrane  are  designated  as 
purpura.  When  small  they  are  called  petechial ;  when  large  they  are  called 
ecchymoses.     Purpura  is  frequently  associated  with  the  infectious  diseases. 

Martha  B.,  7  years  old,  was  brought  to  the  Willard  Parker  Hospital  August  31, 
1903.  She  had  been  ill  two  days  before  admission.  The  diagnosis  of  nasal  diphtheria 
was  made.  On  admission  the  pulse  was  1.58.  Two  days  later  it  dropped  to  90,  and 
on  the  third  day  the  pulse-rate  sank  from  96  to  66.     A  general  purpura  was  notice- 

45 


706 


DISEASES    OF    THE    BLOOD. 


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able.  There  were  bluish  discolorations  of  the  skin  visible  on  the  extremities.  Dr. 
Burckhalter,  the  resident  physician,  called  my  attention  to  a  hsematuria.  The  case 
ended  fatally. 

purpuea  hemorrhagica  (morbus 
Maculosus  Werlhofii.) 

This  is  the  most  severe  form  of 
purpura.  The  lesions  are  a  series  of 
hsemorrhages  confined  to  the  naueous 
membrane  and  skin.  On  the  skin 
purpuric  spots  are  seen  which  de- 
note hemorrhages.  These  haemor- 
rhages are  seen  in  the  lower  and  up- 
per extremities ;  also  on  the  face  and 
abdomen.  The  conjunctival  mu- 
cous membrane  shows  ecchymotic 
areas.  The  gums  bleed  easily  and 
there  are  haemorrhagic  areas  on  the 
soft  and  hard  palate.  Hematuria 
and  haemoptysis  are  sometimes  seen. 
Diagnosis. — The  only  disease 
that  might  be  taken  for  purpura  is 
scurvy,  but  the  general  history  of 
the  case  associated  with  malnutri- 
tion will  clear  up  any  doubt. 
Treatment. — Eest,  iron,  small  doses  of  ergot  and  hydrastis  internally, 

lemons,  oranges,  and  a  nutritious  diet.     Aromatic  sulphuric  acid  in  5-drop 

doses,  several  times  a  day,  should  be  remembered. 

Purpura  Kheumatica  (Peliosis  Rheumatica:    Schonlein's  Disease). 

The  association  of  haemorrhages  with  affections  of  the  joints  charac- 
terizes this  disease.  It  has  frequently  been  noted  that  there  is  tenderness 
in  the  joints  during  the  course  of  simple  purpura.  But  the  more  pro- 
nounced form  of  fever,  in  conjunction  with  swellings  and  tenderness  of 
the  joints,  'plus  the  characteristic  appearance  of  the  subcutaneous  haemor- 
rhages appearing  in  purpuric  spots,  differentiate  peliosis  from  simple  pur- 
pura. 

Associated  with  this  rheumatic  affection  we  frequently  have  extravasa- 
tions of  blood  and  serous  effusions  into  the  joints,  giving  a  decided  fluc- 
tuating feeling.  One  very  important  point  is  the  fact  that  cardiac  lesions 
do  not  complicate  this  condition.  Cases  of  this  kind  have  frequently  been 
reported,  and  Baginsky  lays  stress  on  the  non-existence  of  heart  lesions 
in  this  affection. 


Fig.  227. — Malignant  Purpura  Compli- 
cating Nasal  Diphtheria.  General  sepsis. 
Toxic  JNephritis,  meningitis,  myocarditis. 
Note  pulse.     Fatal.      (Original.) 


PURPURA.  -VQt 

The  following  case  came  under  my  observation^: — 

A  child,  George  P.,  about  9  years  old,  was  attacked  with  pains  in  his  feet  and 
cried  when  attempting  to  walk.  He  had  had  some  very  violent  exercise  during  the 
four  or  five  weeks  preceding  this  attack  by  riding  a  bicycle  as  much  as  four  and  tive 
hours  daily.  The  mother  stated  to  me  that  he  had  frequently  complained  of  joint 
pains,  but  she  attributed  them  to  "growing."  She  noted,  however,  that  after  bicycle 
riding  the  boy's  pain  was  much  more  intense.  His  general  condition  was  otherwise 
healthy.      The  examination  gave  me  the  following  status: — 

A  very  well  nourished  boy:  muscular  and  adipose  tissues  quite  well  developed, 
and  very  tall  for  his  age.  His  weight  was  84  pounds.  The  examination  of  the 
thorax  showed  both  heart  and  lungs  normal;  no  cough;  heart  sounds  regular, 
strong;  pulse,  96.  The  temperature  was  100.2  in  the  rectum,  and  respiration  36. 
The  tongue  was  slightly  coated ;  appetite  good ;  bowels  always  inclined  to  constipa- 
tion; but  recently  since  riding  the  bicycle,  very  much  improved.  Intellect  free,  and 
the  boy  is  mentally  well  developed. 

The  examination  of  the  joints  showed  severe  tenderness  and  swelling  in  both 
knees  and  ankles;  slight  pain  on  palpating  or  rotating  the  hip  joint.  The  most 
marked  tenderness  and  swelling  was  found  at  the  knee  joints.  The  upper  extremi- 
ties— shoulder,  elbow  and  wrist — were  perfectly  normal,  as  far  as  palpation  and 
inspection  could  demonstrate.  The  eruption  on  the  skin  was  of  a  purplish  or  bluish 
color,  and  looked  like  a  distinct  subcutaneous  haemorrhage.  It  was  confined  to  the 
lower  extremities,  covering  almost  completely  the  inner  portions  of  both  thighs,  the 
ankles,  and  more  esj>ecially  the  calves  of  both  legs.  The  spots  were  very  irregular  in 
outline,  in  some  places  confluent,  resembling  more  particularly  the  eruption  of 
morbilli. 

The  child  was  put  to  bed,  the  joints  were  rendered.  Immobile  by  applying  woolen 
roller  bandages  over  them,  and  locally  over  each  joint  some  salicylic  collodion,  10  per 
cent.,  was  applied  with  a  camel's-hair  brush. 

The  main  point  in  the  treatment  which  I  laid  stress  upon  was  to  have  absolute 
rest,  and  it  was  for  this  reason  that  I  put  the  child  to  bed,  that  I  painted  salicylic 
collodion,  and  that  I  put  a  roller  (flannel)  bandage  on  the  legs  and  covered  both 
limbs  from  the  toes  to  the  hip  joint.  Internally  I  gave  ergotine,  V50  grain  every  four 
hours,  besides  15  drops  of  tinct.  ferri  acet.  feth.  in  water  after  each  meal,  three 
times  a  day.  The  spots  gradually  changed  from  a  deep  bluish  color  to  a  brown; 
then  after  ten  days  to  a  light  yellowish  color,  and  after  twenty-seven  days  they  could 
scarcely  be  seen  with  the  naked  eye. 

This  case  has  a  very  interesting  clinical  history.  The  question  that  arose  in 
my  mind  was:  Did  the  violent  exercise  on  the  bicycle  cause  the  inflammation  of 
the  joints  and  possibly  also  the  subcutaneous  ha?morrhages?  On  looking  over  the 
previous  history  of  the  child,  I  found  that  he  had  been  well  nourished,  breast-fed 
until  eleven  months,  and  then  weaned ;  commenced  walking  at  1  year,  and  talking  at 
same  age.  Dentition  began  at  seven  months,  and  when  eight  months  had  two  lower 
and  two  upper  incisors;  the  child  had  seven  teeth  at  eleven  months,  at  time  of  wean- 
ing. 

There  is  no  sign  of  rickets,  althoiigh  there  is  a  large  belly,  rather  pendulous, 
and  the  previous  history  of  constipation.  The  ribs  are  noi-mal,  the  long  bones  well 
developed;  spine  and  thorax  as  good  as  desired.  I  could  obtain  no  data  concerning 
time  of  closure  of  fontanels.  There  is  no  history  of  hipmophilia;  no  previous  bleed- 
ing;    no   epistaxis;     no   haiuioptysis;     both   parents   of   the   child   living,   and  both 


*  Pediatrics,  vol.  ix,  No.  10,  1900. 


'J'08  DISEASES    OF  '  THE    BLOOD. 

healthy.  The  child,  has  had  measles,  complicated,  with  bronchitis,  when  3  years  old, 
lasting  in  all  about  one  month.  No  disease  previous  to  this;  no  summer  complaint, 
and  nothing  since  that  time. 

There  is  no  evidence  of  scurvy;  teeth  are  well  developed,  perfectly  normal;  the 
glims  are  healthy.  The  mother  had  two  other  children — one  now  nursing  and  one 
4V2  years  old.     She  has  had  no  miscan'iages ;    no  reason  to  suspect  lues. 

I  believe  the  etiological  factor  in  this  case  was  the  traumatic  element,  namely, 
the  violent  exercise  causing  both  the  hsemorrhages  and  the  inflammatory  affection  of 
the  joints. 

Henoch's  Puepuea. 

Hsemorrhagic  areas  confined  to  the  abdomen  and  lower  extremities 
are  sometimes  seen.  There  is  also  vomiting  and  abdominal  symptoms, 
such  as  diarrhoea  (bloody  stools)  and  colicky  pains.  There  is  marked 
distension  of  the  abdomen  and  pains  in  the  Joints.  This  condition 
resembles  that  which  has  already  been  described  in  the  article  on  "Purpura 
Eheumatica.''  . 

LlTH^MIA    (LiTHUEIA). 

Haig  and  Eachford  have  given  us  a  very  clear  conception  of  this  con- 
dition, which  is  simply  an  excess  of  uric  (lithic)  acid  in  the  blood.  Haig 
designates  this  condition  as  uricacidgemia.  Other  writers  call  it  lithuria. 
Eachford  calls  this  "leucomain  poisoning." 

Etiology. — When  this  condition  is  met  with  in  children,  we  can  usually 
look  to  the  lithgemic  ancestors  for  the  origin  of  the  disease.  Imprudent 
diet,  such  as  excess  of  prdteids,  may  be  a  factor.  Sedentary  life  and  lack 
of  proper  metabolism  invite  this  condition.  The  alloxuric  bodies  are  ex- 
creted by  the  skin,  kidneys,  and  intestinal  canal.  These  bodies  are  removed 
by  the  kidney  cells  from  the  blood  into  the  urine.  When  they  are  in  excess 
they  must,  therefore,  have  been  present  in  solution  in  the  blood  before  their 
elimination. 

The  presence  of  uric  or  lithic  a.cid,  xanthin,  hypoxantliin,  hetero- 
xanthin,  and  paroxanthin  are  the  factors  causing  this  trouble.  We  are 
still  in  the  dark  concerning  the  manner  in  which  these  bodies  act. 

If  the  kidneys  are  diseased  these  bodies  are  retained  and  the  skin  is 
called  upon  to  do  the  M^ork  which  the  kidneys  fail  to  do.  Thus  it  is  that 
hot  baths  which  promote  diaphoresis  eliminate  through  the  skin,  in  addi- 
tion to  stimulating  the  action  of  the  kidneys. 

Symptoms. — The  new-born  lithasmic  infant  frequently  eliminates  an 
excess  of  urates  during  the  first  few  days  of  life.  In  such  infants  crystals 
of  uric  acid  may  be  precipitated  into  the  tubules  of  the  pyramids  of  the 
kidney.  Jacobi  says  tliat  these  uric  acid  infarctions  may  subsequently  be 
w^ashed  out  of  the  tubules  and  serve  as  the  nuclei  of  urinary  calculi, 

Nocturnal  incontinence  is  frequently  a  symptom  of  lithamia.     True 


PLATK  XXXIII 


Henoch's  Purpura.     Note  ecehyniotic  spots  on  lower 
extremities.      (Original.) 


UTB.JKMIA.  700 

arthritic  gout  resulting  from  uratic  deposits  in  the  tissues  about  the  joints 
is  very  rare  in  childhood. 

Fever,  crying  while  the  child  passes  urine,  scanty  urine  which  usually 
deposits  a  reddish  sand  on  the  diaper,  and  irritation  of  the  external  genitals 
are  the  symptoms  which  appear  at  the  time  of  urination.  The  urine  is 
very  acid  and  we  speak  of  this  condition  as  "a  uric  acid  form  of  lithaemia." 
Sometimes  there  are  gastro-enteric  manifestations,  such  as  vomiting,  head- 
ache, gastric  pain,  convulsions,  a  sickening  odor  of  the  breath,  and  consti- 
pation. These  gastric  symptoms  bear  no  relation  to  improper  diet.  They 
are  usually  met  with  in  children  who  are  carefully  guarded  as  to  the  diet. 
Such  children  are  extremely  nervous  and  irritable.  Eczema  is  a  very  com- 
mon manifestation  of  this  condition.  Unless  a  proper  understanding  of 
this  condition  exists  it  will  persist  and  be  difficult  to  relieve. 

The  urine  in  lithaemia  is  high  colored;  the  specific  gravity  increased. 
On  standing,  there  is  a  sediment  of  red  sand  (urates).  If  the  urine  is 
examined  immediately  after  a  paroxysm  then  the  poisonous  xanthin  bodies 
previop'^ly  mentioned  may  be  found  present.  Transient  albuminuria  is 
occasionally  met  with. 

Treatment, — The  diet  is  the  most  important  part  of  the  treatment. 
Cereals  must  be  given ;  beef  juice,  soups,  broths,  and  fruits.  No  alcoholics 
should  be  given;  in  fact,  all  rich  and  heavy  articles  of  food  must  be  ex- 
cluded. Meat  must  be  given  sparingly.  Salads  and  gravies  are  objection- 
able. Infants  require  massage.  This  passive  form  of  exercise  will  stim- 
ulate the  circulation.  If  children  are  old  enough  to  exercise,  then  exercise 
should  form  an  important  part  of  the  treatment. 

Drug  Treatment. — Calomel  should  always  be  given  in  the  commence- 
ment of  the  treatment.  We  must  aid  in  keeping  the  bowels  loose  during 
the  whole  course  of  treatment. 

Salicylate  of  soda  and  salol  are  useful  eliminatives.  Phosphate  of 
sodium  and  benzoate,  especially  if  eczema  exists,  are  valuable.  Alkaline 
waters,  such  as  white  rock  and  apollinaris,  may  be  given  ad  libitum. 
The  Carlsbad  waters  have  the  same  eliminative  effect.  Dilute  hydrochloric 
acid  or  dilute  phosphoric  acid  in  3  to  5-drop  doses  before  meals  is  es- 
pecially indicated  when  severe  headache  and  gastric  symptoms  exist. 
Urotropin  in  3-grain  doses  may  be  given  in  tablet  form, 

HEMOPHILIA. 

This  is  usually  an  inherited  condition.  It  is  characterized  by  a  ten- 
dency to  bleed,  hence  the  term  "bleeder"  is  applied  to  this  class  of  cases. 
Whole  families  are  found  in  which  this  tendency  to  bleed  exists. 

Pathology. — The  walls  of  the  l)lood-vessels  show  no  alteration,  either 
macroscopically  or  microscopically,  "The  swelling  of  the  joints  is  due  to 
haemorrhages  into  the  articulations  and  into  the  surrounding  tissues.    The 


710  DISEASES  OF  THE  BLOOD. 

tissues  are  blanched  from  loss  of  blood."  The  surface  of  the  body  shows 
petechige  or  bruised  patches. 

Symptoms. — The  appearance  of  the  child  does  not  always  disclose  the 
tendency  to  bleed.  It  is  only  when  an  operation  is  performed,  or  an  in- 
jury exists,  that  alarming  and  frequently  fatal  hasmorrhages  are  seen. 
Epistaxis  is  the  most  common  symptom  noted.  Swelling  of  the  joints 
resembling  rheumatism  is  frequently  seen.  The  bleeding  takes  place 
from  the  capillaries,  most  often  an  oozing  which  may  continue  for  weeks. 
The  subjects  of  haemophilia  are  sensitive  to  cold. 

In  the  chapter  on  "Syphilis"  I  have  already  described  a  case  of  bleed- 
ing in  which  the  lesions  of  syphilis  were  present. 

Annie  G.,  13  years  old,  was  breast-fed  in  infancy.  She  had  diphtheria  when 
1  year  old.  Had  pertussis  when  2  years  old,  which  lasted  nine  weeks.  Has  had 
pneumonia  twice.  No  history  of  rheumatism  given  and  has  had  no  other  infectious 
disease. 

Eistory  of  Bleeding. — ^Has  always  been  troubled  with  haemorrhages.  The  nose 
bleeds  at  the  slightest  provocation.  Blood  spitting  is  quite  common.  The  slightest 
irritation  of  the  bowels  with  looseness  is  associated  ^vith  blood  in  the  stools.  Large 
varicose  veins  are  found  over  the  legs.  There  are  a  number  of  scattered  nsevi.  Not 
infrequently  the  veins  of  the  legs  bleed  daily  for  a  period  of  twenty  or  thirty  days. 

The  Heart. — There  is  a  loud  systolic  murmur  heard  in  front  and  behind,  and 
transmitted  to  the  side.  This  endocarditis  is  a  sequela  to  the  attack  of  diphtheria. 
The  child's  weight  when  seen  by  me  was  67  pounds.  Stypticin  seemed  to  do  more 
good  than  ergot  internally.  Hydrastinine  hydrochlorate,  Ve  grain  three  times  a  day, 
seemed  to  check  the  bleeding  during  another  attack.  When  last  seen  by  me  the  child 
was  developing  fairly  well. 

ProgTiosis. — This  depends  on  the  frequency  of  the  haemorrhages  and 
the  child's  general  condition.  In  152  cases  reported  by  Grandidier  more 
than  one-half  died  before  completing  the  seventh  year,  and  only  nineteen 
attained  majority.^ 

Treatment. — All  operations,  no  matter  how  slight,  should  be  avoided 
if  possible.  Even  the  extraction  of  a  tooth  must  be  seriously  considered, 
owing  to  the  danger  of  bleeding. 

The  diet  should  consist  principally  of  vegetables  and  fruits.  When 
bleeding  occurs,  immediate  treatment,  consisting  of  ice  and  Monsell's  solu- 
tion, should  be  used  locally.  Internall}^,  gallic  acid  and  hydrastine,  % 
grain,  repeated  every  three  or  four  hours.  If  intestinal  haemorrhage  exists, 
colon  flushings  of  iced  water,  temperature  of  50°  F.,  containing  1  drachm 
of  alum  to  1  pint  of  water,  may  be  tried.  An  injection  of  15  to  35  cubic 
centimeters  human  blood  serum  is  an  excellent  haemostatic.  If  this  cannot 
be  secured  then  an  injection  of  15  to  30  cubic  centimeters  of  sterile  horse 
serum  may  be  given.  In  the  case  of  a  ''bleeder,"  recently  seen  by  me  in 
the  Babies'  Wards  of  the  Sydenham  Hospital,  one  injection  of  horse  serum 
controlled  the  haemorrhage  due  to  a  paracentesis,  after  all  locq,!  means  failed. 

*  See  article  in  "Starr's  Textbook," 


CHAPTER  IV. 

DISEASES  OF  THE  GLANDS  OR  LYMPH  NODES. 

The  Thymus  Gland. 

This  long  lobulatcd  gland  is  similar  in  structure  to  the  salivary  glands. 
It  lies  in  the  anterior  mediastinum,  immediately  behind  the  manubrium 
of  the  sternum.  The  thymus  readies  its  full  development  during  the  second 
year,  after  which  it  gradually  disap2:)ears.  The  function  of  the  thymus  is 
still  a  question,  although  it  is  believed  to  have  a  function  similar  to  the 
spleen.  Sudden  death  has  frequently  been  attributed  to  an  enlarged  thy- 
mus. Tuberculosis  involving  the  thymus  gland  is  occasionally  seen  in  cur- 
rent literature. 

Status  Lymphaticus, 

This  condition  is  found  in  rachitic  children,  and  is  of  especial  interest 
because  of  the  enlarged  glands  at  the  angle  of  the  jaw  in  addition  to  the 
adenoids  in  the  vault, of  the  pharynx,  and  enlargement  of  the  lingual  tonsil. 

The  cervical,  bronchial,  axillary,  or  the  inguinal  glands  are  enlarged. 
There  is  also  a  tendency  to  swelling  of  the  parts.  Enlarged  lymph  nodes 
at  the  angle  of  the  jaw  and  hyperplasia  of  the  connective  tissue  of  the  nose 
and  pharynx  are  seen. 

The  thymus  gland  is  very  much  swollen,  and  this  is  believed  to  be  the 
cause  of  sudden  death  in  many  cases. 

Escherich  believes  that  the  pathological  condition  of  the  thymus  gland 
causes  a  form  of  acute  intoxication  resulting  in  cardiac  syncope  and  paral- 
ysis.    This  condition  must  not  be  confounded  with  scrofulosis. 

Escherich  has  reported  a  case  in  which  laryngeal  spasm  occurred  thirty 
times  a  day.  In  such  cases  the  danger  of  asphyxia  should  be  borne  in  mind. 
The  condition  is  of  importance  because  of  the  danger  involved  during  the 
administration  of  an  anaasthetic. 

The  following  case  was  seen  by  me  in  consultation  with  Dr.  A.  W. 
Newfield  during  the  summer  of  1904: — 

The  infant  was  breast-fed,  hnt  did  not  soem  to  nurse  well.  The  lymph  nodes  at 
the  angle  of  the  jaw,  the  groin,  axilla,  and  various  portions  of  the  scalp  could  be 
plainly  felt.  The  child  had  laryngeal  spasms.  Had  had  as  many  as  twenty-five  or 
thirty  attacks  of  laryngismus  stridulus.  The  adenoid  tissue  at  the  base  of  the 
tongue  was  enlarged.  There  was  also  a  mass  of  adenoids  in  the  posterior  nares. 
The  posterior  pharyngeal  wall  was  studded  with  fungous  granulations.  The  infant 
had  a  very  short,  thick  neck.  The  nurse  in  charge  was  always  afraid  the  infant 
would  die  during  these  spasms.      It  was  necessary  to  gavage  to  sustain  life.      By 

(711) 


712  DISEASES  OF  THE  GLANDS  OR  LYl^'IPH  NODES. 

pumping  some  of  the  breast-milk  and  using  cows'  milk  for  alternate  feedings  we 
gradually  strengthened  the  infant. 

Codliver-oil  inunctions  were  ordered  to  aid  in  the  nutrition  of  the  body. 

When  such  a  condition  is  found,  great  care  must  be  exercised  so  as  not 
to  lower  the  vitality  of  the  patient,  but  rather  to  stimulate  nutrition  by 
giving  arsenic  in  the  form  of  Fowler^s  solution  in  addition  to  iodide  of 
sodium. 

Diseases  of  the  Thymus  Glakd. 

In  rare  instances  the  thymus  gland  may  persist  until  the  twentieth  year 
or  even  later  in  life.  When  such  a  condition  exists,  mechanical  pressure  has 
caused  dyspnoea  of  a  serious  nature.  Asthma  has  been  reported  by  some 
clinicians  in  which  an  enlarged  thymus  was  found;  hence  the  term  "thymic 
asthma."  Sudden  death  has  occasionally  been  caused  by  an  enlarged  thy- 
mus. This  has  been  especially  noted  in  children  with  rickets.  Abscesses 
have  been  reported  in  the  thymus  by  Dubois.  Syphilis  and  tuberculosis 
have  rarely  been  found. 

Eeich  says:  "The  absolute  dullness  of  the  thymus,  as  determined  by 
light  percussion,  is  irregularly  triangular  in  outline,  the  base  being  made 
by  the  outline  connecting  the  two  sterno-clavicular  articulations,  the  blunt 
apex  situated  at  the  level  of  the  second  rib  or  slightly  below  it,  and  the 
sides  a  little  beyond  the  edges  of  the  sternum.  The  larger  half  of  this 
triangle  of  dullness  usually  falls  to  the  left  side.  When  the  limits  of  dull- 
ness, as  given  above,  vary  by  one  or  more  centimeters,  or  obscure  the  pul- 
monary resonance  between  the  upper  line  of  cardiac  dullness  and  the  lower 
lateral  limits  of  thymus  dullness,  an  enlargement  of  the  thymus  is  probable. 
The  thymus  dullness  is  present  until  the  end  of  the  fifth  year,  after  which 
it  is  inconstant." 

Diagnosis. — ^The  diagnosis  of  diseases  of  the  thymus  gland  is  frequently 
impossible.  An  infiltration  or  swelling  of  the  area  surrounded  by  the  thy- 
mus gives  rise  to  symptoms  of  dyspnoea,  from  pressure  upon  the  pneumo- 
gastric  nerve.  The  same  symptoms  are  also  found  when  the  thymus  itself 
is  enlarged.  When  the  lymph  glands  in  the  anterior  mediastinum  are 
swollen,  dullness  on  percussion  is  rare  unless  there  is  a  cheesy  infiltration 
of  the  lymph  glands,  according  to  Eeich. 

Treatment. — Symptomatic  treatment  only  should  be  instituted.  The 
iodide  of  sodium  in  very  large  doses  may  be  tried. 

Acute  Adenitis. 

.  This  inflammatory  condition  of  the  lymphatics  is  quite  common.  It 
is  usually  caused  by  an  infection,  or  an  abrasion  of  the  skin,  permitting  m 
infection  in  or  about  the  glands  affected. 


ADENITIS.  713 

The  cervical  glands  are  most  frequently  affected. 

Inflammatory  conditions  in  the  nose,  throat,  the  mouth,  or  on  the 
skin  give  rise  to  these  swellings. 

The  axillary  glands  are  frequently  swollen,  due  to  septic  absorption 
following  vaccination. 

The  glands  of  the  thigh  and  the  inguinal  glands  are  commonly  affected 
when  there  are  irritations  or  inflammatory  lesions  involving  the  genitals, 
or  the  lower  extremities. 

Pathologry. — ^The  glands  show  swelling  and  infiltration  with  inflam- 
matory products.  The  immediate  tissues  are  usually  involved.  Very  fre- 
quently the  swollen  glands  resolve.  At  other  times  there  is  an  excessive 
migration  of  white  cells  so  that  the  glands  break  down  and  abscess  results. 

Symptoms. — The  glands  per  se  may  show  inflammatory  symptoms,  such 
as  fever,  tenderness,  and  swelling.  It  is  wise  to  examine  the  adjacent  parts 
to  be  sure  that  the  glands  are  not  a  secondary  inflammatory  condition.  For 
example,  in  diphtheria  the  neighboring  glands  are  usually  swollen.  If  the 
gland  only  is  involved,  we  have  no  evidence  of  reddening  or  inflammation. 
When  inflammation  exists  involving  the  neighboring  tissues,  a  reddening 
of  the  skin  takes  place.  Such  cases  usually  have  fluctuations,  or  soft  areas 
can  be  made  out.  The  glands  are  swollen,  at  times  reaching  the  size  of  a 
hen's  egg. 

The  diagnosis  is  very  easily  made. 

The  prognosis  depends  on  the  condition  of  the  child  at  the  time  of 
infection.  If  tuberculosis  exists,  the  prognosis  is  bad.  The  prognosis  of 
acute  adenitis  in  conjunction  with  acute  exanthemata  is  usually  good. 

Treatment. — (a)  Abortive;  (b)  surgical. 

Abortive. — ^The  inunction  of  Crede  ointment  has  served  me  very  well. 
A  piece  of  the  salve  about  the  size  of  a  bean  should  be  well  rubbed  into 
the  swollen  gland.  The  rubbing  should  be  continued  at  least  ten  minutes. 
Sometimes  a  leech  applied  to  a  gland  will  reduce  the  swelling.  An  ice-bag 
will  reduce  swelling  and  sometimes  prevent  suppuration.  Belladonna  oint- 
ment and  ichthyol,  10  per  cent.,  with  lanoline  is  sometimes  useful. 

Surgical  Treatment. — ^When  fluctuation  is  felt,  hot  fomentations  with 
flaxseed  meal  will  be  very  grateful.  An  incision  should  be  made,  with 
aseptic  detail,  pus  evacuated,  and  the  wound  packed  with  iodoform  gauze. 

Later  restorative  treatment,  such  as  malt,  iron,  codliver-oil,  or  the 
syrup  of  the  iodide  of  iron,  should  be  given. 

Chronic  Adenitis. 

Not  infrequently  we  meet  with  children  who  have  swollen  glands  last- 
ing months  and  years  ip.  whom  po  evi^ieng^  of  tuberculosis  or  syphilid 
exists. 


714  DISEASES  OF  THE  GLANDS  OR  LYMPH  NODES. 

This  is  usually  due  to  repeated  attacks  of  inflammation  following 
acute  adenitis,  or  it  is  the  result  of  chronic  inflammation  of  the  skin. 

Pathology. — ^The  glands  show  an  increase  in  their  cellular  and  con- 
nective-tissue elements.     They  undergo  a  true  hyperplasia. 

Symptoms. — The  symptoms  consist  in  a  swelling  of  the  glands  without 
inflammation  or  tenderness.  In  chronic  adenitis  the  glands  do  not  break 
down;  hence  suppuration  is  absent.  In  conjunction  with  chronic  enlarged 
glands,  we  find  hyperplasia  of  the  tonsils,  so  that  we  invariably  have  en- 
larged tonsils  and  adenoids  in  such  conditions. 

Diagnosis. — ^The  diagnosis  should  be  made  after  sjrphilis,  tuberculosis, 
and  other  infections,  such  as  diphtheria  and  scarlet  fever,  have  been  ex- 
cluded, so  that  we  can  be  sure  no  specific  or  infectious  disease  is  the  origin 
of  the  trouble. 

The  progniosis  is  usually  very  good. 

Treatment. — ^The  treatment  consists  in  removing  the  cause.  Middle- 
ear  inflammation,  scalp  disease,  and  pediculosis  should  be  vigorously  treated. 
Adenoids  and  diseased  tonsils  should  be  removed.  Thus  the  treatment  is 
narrowed  down  to  removing  the  cause  if  possible  and  relying  on  restorative 
treatment,  fresh  air,  and  good  nutritioii. 

Tubercular  Adenitis. 

This  condition  is  due  to  an  invasion  of  the  tubercle  bacillus,  resulting 
in  a  tubercular  manifestation  of  the  glands.  It  was  formerly  believed  to 
be  "scrofulosis."  The  pharynx  and  tonsils  seem  to  be  the  point  of  entrance, 
as  the  glands  in  the  cervical  region  are  usually  affected. 

Pathology. — ^The  glands  undergo  a  caseous  degeneration  which  fre- 
quently results  in  abscess.  At  times  we  meet  with  tubercular  lesions  in 
various  organs  of  the  body.  In  the  glands  we  note  that  they  are  studded 
with  miliary  tubercles  and  also  find  the  tubercle  bacillus  therein. 

Symptoms. — The  glands  enlarge  in  various  parts  of  the  body;  most 
frequently  the  cervical  glands  are  affected.  It  is  usually  a  very  slow  process, 
extending  over  months;  sometimes  years.  During  this  time,  from  the  long- 
continued  inflammation,  evidence  of  a  continued  illness  is  shown.  When 
these  abscesses  form  they  heal  very  slowly  and  frequently  leave  sinuses  or 
ragged  scars. 

Henry  G.,  2%  years  old,  was  brought  to  my  children's  service  with  a  history 
of  recurring  swelling  on  both  sides  of  the  neck  and  also  behind  the  ear.  The  child 
was  bottle-fed  during  infancy  and  had  always  suffered  with  dyspeptic  trouble  and 
constipation.  He  has  had  furunculosis  of  the  scalp,  which  necessitated  incisions, 
during  the  second  year.  Was  troubled  with  tonsillar  and  catarrhal  trouble ;  also 
double  otitis. 

The  glands  of  the  neck  are  swollen  and  frequently  break  down  and  discharge 
pus.  The  temperature  is  not  elevated.  This  suppuration  is  known  as  the  cold  abscess 
type.     The  general  condition  is  fair.     The  child  is  taking  maltine  with  hypophos- 


TUBERCULAR  ADENITIS. 


715 


phites.    A  restorative  diet  of  cereals,  cream,  butter,  eggs,  etc.,  is  given.    Attention  to 
hygiene  and  out-door  life  is  the  most  important  part  of  the  treatment. 

Diagnosis. — This  can  easily  be  made  when  we  consider  the  character 
of  the  glandular  swelling,  their  tendency  to  caseation,  and  to  suppuration. 
When  the  pus  is  examined,  tubercle  bacilli  are  invariably  found. 

Differential  Diagnosis. — In  the  beginning  this  disease  is  difficult  to 
diagnose.     We  can  exclude  syphilis  by  the  history  of  the  parents.     When 


Fig.    228. — Case  of  Cervical  Adenitis  in  which  a  Positive  von  Pirquet 
Reaction  Appeared.     (Original.) 


the  history  is  not  obtainable,  resorting  to  anti-syphilitic  treatment  will 
materially  aid  in  eliminating  the  diagnosis  of  syphilis.  In  Hodgkin's  dis- 
ease the  glands  do  not  suppurate.  In  simple  chronic  adenitis  there  is  no 
suppuration. 

Treatment. — Attention  to  hygienic  details  is  of  prime  importance. 
The  diet  should  consist  of  restorative  foods  in  which  proteins  and  fats 
abound.  Restorative  medication,  such  as  iron,  codliver-oil,  iodide  of  sodium, 
and  arsenic,  and  syrup  of  iodide  of  iron  are  the  most  useful  drugs  to  be 
considered. 


71i6  DISEASES  OF  THE  GLANDS  ANB  LYMPH  NODES. 

Read  also  the  treatment  outlined  in  the  chapter  on  "Acute  Miliary 
Tuberculosis." 

The  surgical  treatment  of  tubercular  adenitis  should  consist  in  the 
total  removal  of  the  suppurating  glands,  using  aseptic  precaution,  rather 
than  to  rely  on  slow  spontaneous  evacuation  of  pus  by  Nature, 

Mumps  (Specific  Parotitis). 

This  is  a  specific  febrile  disease,  characterized  by  inflammation  of  the 
salivary  glands.  . 

Etiology. — This  disease  is  prevalent  all  over  the  world,  occurring 
usually  in  the  form  of  local  epidemics.  It  is  more  marked  during  the  cold 
and  wet  seasons  than  in  the  summer.  Children  between  10  and  15  years 
of  age  suffer  most.  Boys  are  more  liable  to  be  attacked  than  girls.  Infantile 
parotitis  is  frequently  met  with.  The  nursing  infant  is  not  exempt  from 
this  condition. 

The  perietd  of  incubation,  counting  from  the  exposure  to  infection 
and  the  appearance  of  the  disease,  varies  from  fourteen  to  twenty-five  days. 
It  is  usually  about  three  weeks. 

In  New  York  City,  children  suffering  from  mumps  are  excluded  from 
school  until  the  swelling  has  entirely  subsided.  Children  of  the  family  who 
have  not  had  the  disease  are  excluded  until  the  medical  inspector  recom- 
mends re-admission.  Children  in  the  family  who  have  had  the  disease  may 
remain  in  school. 

How  the  Disease  is  Spread. — Contact  seems  to  be  the  method  of  con- 
veying the  disease  from  person  to  person.  School  children  and  families 
are  thus  infected. 

Pathology. — The  disease  is  most  likely  due  to  an  infection  by  a  micro- 
organism.   The  salivary  glands  are  probably  the  seat  of  invasion. 

Symptoms  and  Diagnosis. — The  disease  begins  with  fever  lasting  two 
or  three  days.  The  temperature  may  reach  104°  F.,  although  the  usual  tem- 
perature is  about  101°  F.  The  fever  may  be  so  pronounced  that  delirium 
accompanies  the  same.  The  most  pronounced  symptom  is  pain  and  ten- 
derness in  one  parotid  gland.  The  gland  becomes  swollen.  The  swelling 
occupies  the  space  behind  the  angle  of  the  jaw  and  below  the  ear,  spreading 
forward  on  the  cheek,  and  downward  along  the  neck.  The  edge  is  ill  de- 
fined, and  the  swelling  itself  is  doughy  to  the  touch. 

Goodhart  has  reported  cases  in  which  the  swelling  was  severe  and  the 
patient  breathed  with  his  mouth  open.  In  such  instances  the  tongue  is  dry 
and  brown,  but  no  serious  import  should  be  given  thereto. 

The  swelling  is  confined  to  that  portion  of  the  neck  between  the  Jaw 
and  the  stemo-cleido-mastoid  muscle.  The  center  of  the  swelling  is  im- 
mediately under  the  lobe  of  the  ear. 


MUMPS.  717 

The  swelling  becomes  so  extreme  and  the  pain  so  acute  that  the  patient 
can  hardly  do  more  than  separate  the  upper  and  lower  jaw.  The  submax- 
illary gland  on  the  same  side  becomes  affected  within  a  day  or  two  and  there 
is  a  large  swelling  below  the  jaw.  Soon  afterward  the  opposite  parotid 
and  submaxillary  glands  may  also  become  involved.  Goodhart  states  that 
a  swelling  of  the  cervical  lymphatic  glands  may  be  the  only  local  signs  of 
mumps. 

There  is  usually  a  general  malaise.  The  swelling  lasts  four  or  five 
days  and  then  subsides.  Suppuration  never  results.  The  amount  of  saliva 
secreted  is  not  lessened.     In  many  cases  it  may  be  excessive. 

Differential  Diagnosis. — The  glandular  swelling  in  mumps  has  fre- 
quently been  mistaken  for  diphtheria.  In  the  latter  disease  the  parotid 
glands  are  not  affected.  The  patient  rarely  encounters  difficulty  in  opening 
the  mouth,  even  when  the  cervical  lymph  glands  are  enlarged. 

The  differential  diagnosis  between  mumps  and  diphtheria  must  be 
made  by  a  careful  inspection  of  the  fauces  and  tonsils  and  noting  the  ab- 
sence, or  presence  of  membrane. 

There  are  other  conditions  which  may  be  accompanied  by  parotitis. 
In  enteric  and  other  fevers  in  various  disorders  of  the  abdominal  cavity, 
one  or  both  parotids  may  be  inflamed.  In  these  conditions,  however,  sup- 
puration of  the  parotid  gland  may  ensue. 

Prognosis. — This  is  almost  always  favorable.  Goodal  and  Washbourn 
state  that  during  ten  years  in  England  and  Wales  there  were  but  eighty 
deaths  registered  among  the  entire  population.  These  authors  suspect 
diphtheria  as  the  cause  of  most  of  these  deaths,  reported  as  mumps. 

Complications. — The  most  disagreeable  complication  is  orchitis.  This 
usually  commences  when  the  disease  has  progressed  several  weeks.  It  is 
accompanied  by  fever,  sometimes  chills.  The  body  of  the  testicle  and  not 
the  epidermis  is  involved.  As  a  rule  ice-bags  or  leeches  aided  by  rest  will 
relieve  this  condition.  The  attack  usually  lasts  several  days,  but  may  be 
prolonged  several  weeks. 

Treatment. — Local:  Hot  fomentations,  consisting  of  ground  flaxseed 
meal  to  which  a  few  drops  of  laudanum  have  been  added,  are  very  grateful 
and  well  borne.  They  are  to  be  applied  between  two  thicknesses  of  cheese- 
cloth. These  poultices  should  be  renewed  at  intervals  of  one-half  hour. 
Among  the  newer  local  remedies,  antiphlogistine,  warmed  and  applied  in 
the  form  of  a  salve,  has  been  advocated. 

The  occasional  application  of  a  leech  at  the  site  of  the  swollen  parotid 
will  be  found  advantageous  in  some  instances. 

An  ice-bag  can  sometimes  be  used  to  advantage.  The  local  application 
of  tincture  of  iodine  can  be  recommended. 


718  MUMPS. 

The  inunction  of : — 

B  Unguentum  belladonna 6  drachms 

Unguentum  hydrarg.  ciner 3  drachms 

M.     Ft.  ungt. 

To  be  rubbed  in  swollen  glands  every  three  or  four  hours,  may  be  tried. 

Another  drug  which  is  quite  serviceable  is  ichthyol,  to  be  applied  sev- 
eral times  a  day,  in  the  following  manner: — 

IJ  Ammonium  sulpho.  ichthyol 2  drachms 

Lanoline 1  ounce 

M.      Ft.  unguentum. 

To  be  thoroughly  rubbed  in  swollen  glands. 

The  local  application  of  a  5  per  cent,  iodoform  collodion  painted  over 
the  inflamed  region,  several  times  a  day,  or  a  10  per  cent,  salicylic  collodion 
applied  several  times  a  day  is  at  times  beneficial. 

The  inunction  of  a  15  per  cent,  iodide  of  potassium  ointment  will  be 
indicated  if  there  is  a  suspicion  of  syphilis  in  the  case. 

Constitutional  Treatment. — Rarely  do  we  require  internal  medication 
in  this  disease.  If,  however,  there  is  high  fever,  sponging  the  surface  of 
the  body  or  cold  packs  are  indicated.  The  internal  administration  of  a  mild 
laxative,  such  as  citrate  of  magnesia,  is  grateful  and  beneficial. 

Five-grain  tablets  of  rhubarb  and  magnesia  will  be  required  if  consti- 
pation exists. 

Owing  to  the  infectious  nature  of  this  disease,  the  first  rule  should  be 
to  isolate.  The  isolation  should  be  thorough  and  continued  at  least  ten 
days  from  the  beginning  of  the  illness. 


CHAPTER  V. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

Cretinism  (Myxcedematofs  Idiocy — Myxgedema). 

Cretinism  is  a  form  of  'idiocy  associated  with  pachydermatous 
cachexia. 

Etiology. — In  my  own  cases  psychical  disturbances  in  the  mother 
seemed  to  result  in  cretinism.  Worriment  and  fright  seemed  to  have  some 
etiological  relationship  to  the  development  of  myxoedematous  idiocy. 

In  two  cases  of  mine  the  mother  suffered  with  mental  depression,  con- 
stant worry,  and  hysterical  symptoms  during  pregnancy. 

Pathology. — We  are  indebted  to  Fletcher  Beach  for  a  series  of  careful 
post-mortem  investigations  which  have  thrown  considerable  light  on  the 
nature  of  this  disease.  We  know  that  cretinism  is  due  to  the  absence  of 
the  internal  secretion  of  the  thyroid  gland.  In  some  instances  the  gland 
is  congenitally  absent.  This  condition  also  results  when  the  thyroid  gland 
is  removed  by  surgical  means.  It  is  safe,  therefore,  to  assume  that  the  loss 
of  the  function  of  the  thyroid  gland  causes  cretinism. 

Holt  believes  that  cretinism  is  in  some  instances  associated  with  goiter. 
This  disease  occurs  sporadically  in  our  country. 

Symptoms. — The  characteristic  manifestations  are  very  apparent  dur- 
ing the  first  year  of  a  child's  life.  Sometimes  distinct  evidences  of  cretinism 
can  be  seen  as  early  as  the  third  month  after  birth.  The  child  is  short  in 
stature  and  light  in  weight  compared  to  the  normal  infant.  The  extremi- 
ties, particularly  the  fingers,  are  short  and  thick.  The  lips  are  thick.  The 
tongue  is  broad  and  thick,  and  constantly  protrudes  from  the  mouth.  The 
fontanel  is  late  in  closing.  The  nose  is  broad,  flat,  and  upturned.  The 
nostrils  are  wide  open.  The  hair  is  coarse  and  straight  (straw-like).  Den- 
tition is  delayed,  and  when  the  teeth  do  appear  they  are  very  poorly  formed. 
The  skin  of  the  entire  body  is  thick  and  dry,  but  does  not  pit  on  pressure. 

The  infant  is  stupid,  and  it  is  very  noticeable  that  we  are  dealing  with 
deficient  mental  development. 

In  the  supra-clavicular  regions  there  are  regularly  formed  pads  of  fatty 
tissue,  so  that  the  neck  is  short  and  thick  (Tuttle).  The  thyroid  gland 
cannot  be  felt  unless  it  contains  a  tumor.  The  abdomen  is  large  and 
prominent  and  an  umbilical  hernia  is  frequently  present. 

Constipation  of  a  very  obstinate  character  is  usually  met  with  and 
persists  for  a  long  time.    The  temperature  is  subnormal.    The  th}Toid  gland 

(719) 


720  DISEASES    OF    THE    DUCTLESS    GLANDS. 

is  absent  or  cannot  be  felt.  In  palpating  the  thyroid  region  we  can  feel  the 
trachea.  In  some  cases  there  is  a  hypertrophied  hypothenar  eminence  on 
the  palms  of  the  hands.  The  face  in  all  cases  has 'the  prognathous  expres- 
sion (Koplik). 

Diagnosis. — The  value  of  an  early  diagnosis  in  this  condition  is  more 
important  than  in  any  other  disease  with  which  we  are  brought  in  contact. 
The  diagnosis  can  usually  be  confirmed  after  a  short  period  of  thyroid  treat- 
ment. The  specific  results  of  treatment  are  more  apparent  in  this  condi- 
tion than  in  any  other  infantile  derangement  with  which  we  are  con- 
fronted. 

Case  I. — Frances  P.^  was  referred  to  me  by  Dr.  L,  F.  Haas.  She  was  the 
seventh  child  of  this  family.  All  the  other  children  were  perfectly  normal.  The 
labor  was  normal.     The  child  was  born  before  the  doctor  arrived. 

Family  History. — The  father  is  healthy.  The  mother  is  strong  and  healthy. 
During  the  pregnancy  the  mother  constantly  cried  on  account  of  family  trouble. 
Her  husband  was  out  of  work.  The  mother  frequently  had  hysterics.  Similar 
psychical  disturbances  were  never  present  while  pregnant  with  the  six  other  children, 
who  are  all  strong  and  healthy. 

History  Given  by  the  Mother. — The  mother  noticed  that  the  child  had  short 
limbs.  That  she  was  not  bright  mentally.  That  when  1  Va  years  old  she  could 
neither  walk,  talk,  nor  support  her  head.  The  tongue  was  very  thick  and  protruded 
almost  constantly  while  awake,  as  well  as  when  asleep.  The  hair  did  not  grow. 
The  nose  was  short  and  flattened.  The  skin  Avas  yellowish  and  dry.  The  child  had 
a  jaundiced  appearance.  Constipation  since  birth.  The  bowels  were  moved  with 
difficulty.  The  infant  was  breast-fed  until  it  was  fifteen  months  old.  Up  to  this 
time  there  was  no  sign  of  dentition.  She  was  taken  to  the  Babies'  Hospital, 
which  necessitated  her  being  weaned  from  the  breast.  She  remained  in  the 
hospital  about  two  weeks.  When  sixteen  months  old,  one  month  after  thyroid 
treatment  was  commenced,  the  -first  tooth  appeared.  The  child  was  successfully 
vaccinated  at  the  end  of  the  first  year. 

During  its  first  year  and  up  to  the  time  that  it  was  taken  to  the  hospital,  it 
did  not  suff'er  with  any  infectious  disease. 

My  first  examination  was  on  December  8,  1902.  The  child  at  that  time  was 
2  years,  2  months  old.      The  following  conditions  were  found: — 

The  child  can  neither  walk  nor  talk.  The  tongue  is  very  thick  and  protrudes 
constantly.  The  lips,  the  eyelids,  and  the  skin  of  the  face  are  thickened,  coarse,  and 
rough.  The  nose  is  short  and  flat.  The  skin  has  a  yellowish  jaundiced  appearance. 
The  fontanel  is  widely  open  both  anteriorly  and  posteriorly.  The  face  is  broad  and 
the  eyes  are  set  very  wide  apart.  There  is  a  marked  depression  on  each  side  of  the 
temporal  bone.  There  is  a  marked  frontal  protuberance.  The  child  had  nine 
teeth  when  twenty-two  months  old.  As  previously  stated  the  first  tooth  appeared 
one  month  after  the  thyroid  treatment  was  commenced,  or  when  the  child  was 
sixteen  months  old.  The  body  is  well  developed — fat.  There  is  no  evidence  of 
rachitis.  The  chest  and  spine  show  evidences  of  good  nutrition.  The  length  of  the 
body  was  50  "/j  centimeters,  or  about  20  inches.  The  secretions  of  the  body  were 
very  torpid.  Constipation  of  a  very  obstinate  form  was  encountered.  There  were 
several  fatty  growths  in  the  sterno-cleido-mastoid  muscle. 

^  Three  cases  of  cretinism  were  presented  by  me  at  the  Section  of  Pediatrics 
of  the  New  York  Academy  of  Medicine,  February  11,  1904. 


CRETINISM. 


721 


Spobadic    Cbetinism. 

Fig.      229.— Child. 
years,    2    months, 
nal.) 

Fig.  230.— Same  child.  Seven 
months  after  continued  thy- 
roid treatment.     ( Original. ) 

Fig.  231. — Same  child.  Age 
3  years,  9  months.  One 
year  and  seven  months 
after  continued  thyroid 
treatment.       (Original.) 


•?■?, 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


The  child  had  a  violent  fear  of  water,  so  much  so  that  the  mother  had  difficulty 
in  bathing  her.  The  hair  is.  very  thick  and  straw-like.  The  thyroid  gland  cannot 
be  felt. 

The  pulse  was  90  and  of  a  full  bounding  character.  There  was  a  subnormal 
temperature  which  wa-s  never  higher  than  98°  F.  in  the  rectum  in  the  evening. 
Respiration  was  16  while  quiet  and  24  while  crying.  The  ui'ine  showed  traces  of 
indican,  evidently  due  to  the  constipation.  No  albumin  or  sugar  was  found.  Micro- 
scopically no  uric  acid  crystals;    no  casts,  and  no  bacteria  were  found. 

T\Tien  the  treatment  was  first  commenced,  1  gi-ain  of  thyroid  was  given  three 
times  a  day.  This  dose  was  rapidly  increased  so  that  after  the  first  week  the  child 
took  2  ^/j  grains  three  times  a  day.  The  heart  Avas  carefully  watched  and  no 
disturbance  noted  from  the  quantity  of  thyroid  given.  In  addition,  10  drops  of 
pure  codliver-oil  was  given  three  times  a  day.  Cereals,  milk,  chicken  soup,  broths, 
and  acid  fruits,  such  as  oranges,  lemons,  and  cranberries,  were  ordered.  Fresh  air  and 
bathing,  with  vigorous  friction,  concluded  the  hygienic  treatment.  Under  this 
vigorous  treatment  the  child  developed  A^ery  fast.  The  length  of  the  body  was 
.58  ^/2  centimeters  at  the  end  of  the  first  month  of  this  treatment.  The  growth, 
therefore,  in  one  month  amounted  to  8  centimeters  or  3  Vs  inches.  The  obstinate 
constipation  was  improved  and  the  bowels  became  regular.  The  teeth  have 
appeared  at  regular  intervals.  The  facial  expression  has  changed.  The  child  now 
commences  to  walk,  as  also  to  talk,  she  says  "mamma"  and  "papa." 

The  fear  of  water  and  to  be  bathed  is  past.  She  no  longer  cries  when  she  sees 
water.  At  the  end  of  1  year,  the  length  of  her  body  is  85  centimeters  or  33  V2 
inches,  so  that  she  has  grown  in  1  year  341/2  centimeters  or  13^2  inches. 

The  child  is  still  taking  thyroid  and  is  progressing  favorably. 


Table  No.  74. — Length  and  Growth  of  Body. 


Age. 


Length  of  BoJt. 


Gain  in  Growth  of  Body. 


2  yrs.  and  2  mos. 

2  yrs.  and  3  mos. 

3  vrs.  and  3  mos. 


oOJ  centimeters  (19jf  inches) 
58y  centimeters  (23^^  inches) 
85    centimeters  (33 J  inches) 


1    mo.,    8  centimeters  (3^  inches) 
12  mos.,  34J  centimeters  (13J  inches) 


Case  II. — Rosie  H.,  born  .January  1,  1902,  now  over  2  years  old,  was  first  seen 
by  me  when  she  was  eighteen  months  old. 

Family  History. — Father  living,  is  somewhat  dyspeptic.  Has  no  specific  disease. 
The  mother  is  a  very  nervous  woman,  otherwise  in  good  health.  Tliis  is  her  first 
child.  She  has  had  one  other  pregnancy  of  eight  months  which  was  still-bom, 
believed  to  have  been  an  asphyxia  neonatorum.     No  miscarriages.     No  lues. 

Child's  History. — She  was  breast-fed  for  seven  months,  later  she  received  equal 
parts  of  milk  and  water.  When  first  seen  by  me  at  the  age  of  eighteen  months,  she 
was  still  fed  on  equal  parts  of  milk  and  water.  There  has  always  been  severe 
constipation,  and  streaks  of  blood  have  frequently  been  seen,  in  the  stool  from  severe 
tenesmus.  The  examination  of  the  child  at  that  time  showed  coarse,  sparse  hair, 
and  a  very  rough  skin.  The  tongue  and  the  lips'  were  very  thick.  The  tongue 
always  protruded  from  the  mouth;  breathing  was'  difficult.  There  was  constant 
snoring,  and  the  mouth  was  ahvays  open.  The  thorax  was  decidedly  rachitic;  there 
was  a  funnel-shaped  depression,  and  also  a  kyphosis  and  an  umbilicated  hernia.  The 
child  could  neither  stand  nor  talk.  There  was  no  evidence  of  teething.  The  appetite 
was  poor.      The  temperature  was  subnormal,  98  Vo"  in  the  rectum.      The  pulse  was 


CtlEHNlSM. 


723 


Sporadic   Cretinism. 

Fig.  232.— Oliild.  Age  1 
year,  5  months.  (Origi- 
nal.) 

Fig.  233. — Same  child.     Age 

2  years.      (Original.) 

Fig.  234. — Same  child.    Age 

3  years,  5  months.  (Orig- 
inal. ) 


Fig,  233. 


Fig.  234, 


724  iDiSEASES    OF    THE    DUCTLESS    GLANDS. 

100,  small,  and  feeble.  The  heart  sounds  muffled.  A  hsemic  murmur  was  plainly 
heard  at  the  apex  and  also  in  the  vessels  of  the  neck.  It  was  impossible  to  seciu-e 
a  specimen  of  urine  for  examination.  A  drop  of  blood  was  examined  and  showed  a 
decreased  number  of  red  blood-corpuscles  and  a  marked  leucocytosis.  The  diagnosis 
made  was  sporadic  cretinism.  The  circulation  was  poor  and  there  was  a  slight 
oedema  constantly  present.  The  feet  and  hands  were  frequently  cyanotic,  and  always 
felt  cold.  The  anterior  fontanel  was  widely  open.  Growth  was  stunted  as  the 
length  of  the  body  was  only  55  centimeters.  The  naked  weight  when  1  V2  years  old 
was  11  pounds  13  ounces.  When  first  seen  by  me  there  was  neither  muscular  nor 
bony  development  which  could  be  considered  normal.  At  eighteen  months  the  child 
had  had  no  teeth.  At  twenty-two  months  the  first  tooth  appeared.  The  muscles  of 
the  body  were  limp  and  flabby.  The  child  could  not  support  her  head  nor  was  there 
good  support  to  the  spinal  column.     The  patellar  reflexes  were  but  slightly  present. 

Treatment. — The  treatment  consisted  in  giving  fresh,  raw  milk  warmed  to  body 
temperature.  In  addition  to  the  milk,  steak  juice,  orange  juice,  potato  flour,  and 
the  usual  antiscorbutic  remedies  were  ordered.  Fresh  albumin,  using  the  raw  white 
of  Qgg,  and  vegetable  proteids,  such  as  pea  soup  and  lentil  soup,  were  very  well 
assimilated. 

Tlie  medicinal  treatment  consisted  of  two  drugs.  Thyroidine  was  given  in  doses 
of  V2  gi'ain  three  times  a  day,  and  gradually  increased  until  3  grains  were  given  three 
times  a  day.  The  other  drug  was  Fowler's  solution  given  in  1  di'op  doses,  increased 
to  3  drops  three  times  a  day.  It  is  now  about  six  months  since  the  treatment  was 
commenced.  The  child  has  grown  in  length  from  55  centimeters  to  69  centimeters 
and  the  weight  has  increased  from  11  pounds  13  ounces  to  17  pounds. 

Case  III. — Rosie  N.  was  first  seen  by  me  on  June  28,  1902.  She  was  then 
seventeen  months  old. 

Family  History. — Father  is  healthy.  No  family  history  of  tuberculosis,  syphilis, 
or  any  other  taint.  The  mother  is  in  good  health  and  has  never  had  any  serious 
illness  nor  miscarriage.  This  was  her  first  pregnancy.  The  mother's  condition  was 
good,  there  was  no  traumatism  nor  any  psychic  disturbance.  The  infant  was  born 
without  the  aid  of  instruments.  It  was  a  perfectly  normal  delivery.  The  mother 
menstruated  while  nursing  the  infant. 

Personal  History.— The  infant  was  nursed  about  sixteen  months.  She  did  not 
seem  to  thrive  since  she  was  three  months  old.  Severe  constipation  had  always 
existed,  and  was  present  when  I  first  saw  her.  She  could  neither  stand,  walk,  nor 
talk.  Backwardness  in  development  was  very  apparent.  Spasmus  nutans  was 
present.  The  fontanel  was  widely  open.  She  showed  no  signs  of  intelligence.  The 
hair  was  coarse  and  straight.  The  extremities  were  short.  The  growth  stunted. 
She  presented  a  squatty  appearance.  The  skin  was  rough,  thickened,  and  large 
eczematous  patches  covered  the  aitns  and  legs.  The  child  was  sent  to  me  by  Dr. 
L.  Weiss,  who  had  her  under  his  care  for  the  relief  of  the  eczema.  The  lips  were 
thick.  The  tongue  was  thick  and  protruding.  She  had  two  lower  incisors;  no 
other  evidence  of  dentition.  The  facial  expression  was  senile  and  corresponded  with 
that  of  a  tj'pical  cretin.  She  was  restless  by.  day  and  suffered  with  insomnia  by 
night.  The  urine  was  examined  and  contained  no  albumin  nor  sugar.  Slight  traces 
of  indican  were  seen,  microscopically  nothing  pathological.  The  blood  examination 
showed  four  million  six  hundred  and  twenty  thousand  (4,620,000)  red  blood-cor- 
puscles, and  seven  thousand  two  hundred  (7200)  white  cells. 

The  percentage  of  haemoglobin  taken  with  Gower's  instrument  was  about  40 
per  cent.  As  digestion  was  very  poor  I  decided  to  syphon  off  the  gastric  contents 
two  hours  after  a  meal  and  to  examine  the  same  chemically. 


CRKT[NISM. 


725 


Feeding. — The  feeding  wius  barley  water.  About  5  cubic  centimeters  were 
syphoned  off,  which  showed  traces  of  peptones,  starch,  and  sugar;  HCl  was  absent 
by  (Junzberg's  test.  I  am  indebted  to  Mr.  Charles  LaWall  for  his  assistance  in  the 
chemical  analyses  of  the  gastric  contents,  made  a  number  of  times. 

E(jual  parts  of  milk  and  barley  water  were  fed  every  few  hours.  Thyroid 
treatment  was  conuiieneod ;    '/2  grain  of  the  de.siccatetl  powdered  thyroids  was  ordered 


Fig.      235. — Crjtinism.        Age      7V4      years. 
Height  261/^   inches.      Front   view. 


F:g.      236.— Cretinism. 
Height   261^   inches. 


Aui'      T^i      years. 
Liack   view. 


three  times  a  day.      The  dose  was  gradually  increased  and  the  child  now  receives  3 
grains  three  times  a  day.     There  was  no  cardiac  disturbance  from  this  dose. 

Lemon  juice,  orange  juice,  raw  albumin,  and  vegetable  soups  were  ordered. 
The  child's  condition  improved.     The  specific  effect  of  the  thyroid  was  very  apparent. 

Case  TV. — GTissie  S.,^  7  years  and  3  months  old  when  she  came  under  my  obser- 
vation. She  was  born  January,  1897.  She  is  the  oldest  of  four  children.  The  other 
children  are  to  all  appearances  healthy,  as  are  also  the  parents. 


^  I  regard  this  case  as  the  most  complete  type  of  cretinism  that  I  have  ever 
seen.  The  notes  were  kindly  furnished  by  Dr.  A.  E.  Isaacs,  in  whose  practice  the  case 
occurred. 


726 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


Family  History. — The  mother  claims  to  have  had  a  severe  fright  during  her 
sixth  month  of  pregnancy,  and  attributed  the  child's  mental  deficiency  to  this  psych- 
ical disturbance.      There  is  no  history  of  any  condition  similar  to  this  child's  on 


Fig.  237. — Cretinism.  Same  case.  Age 
8  years.  Height  33%  inches,  gain  6% 
inches. 


Fig.  238. — Cretinism.  Same  case.  Age 
8  years.  Height  33%  inches,  gain  6% 
inches.     Back  view. 


either  side  of  the  family.  Parents  are  natives  of  Russia.  They  are  13  years  in  this 
country,  and  do  not  know  of  any  such  disease  in  their  native  country.  The  parents 
are  not  related. 

Feeding. — The  child  was  breast-fed  for  about  two  years.  She  did  not  receive 
any  other  food  during  this  period.  When  the  child  was  thirteen  months  old  the 
i-iother's  menstruation  returned.  The  mother  continued  to  nurse  the  child  until  the 
end  of  the  second  year,  although  she  continued  to  menstruate  every  month. 

Nothing  unusual  was  noticed  about  this  child  until  the  end  of  her  first  year. 
She  cried  ver^'  little  and  slept  a  great  deal.  At  about  1  year  of  age  parents  noticed 
that  she  differed  from  other  children  of  the  same  age.      No  teeth  appeared.      She 


CRETINISM. 


737 


made  no  attempt  to  walk  or  stand.  Never  laughed  or  smiled,  was  always  apathetic 
and  took  no  inteiest  in  hor  surroundings.  Tliere  was  no  appreciable  growth  in 
height  from  1  to  7  years.  The  same  dresses  always  fitted  her.  In  her  fifth  year 
she  was  for  a  period  of  six  months  very  cross  and  restless,  but  this  disappeared  as  it 
came,  without  any  known  cause. 


Pig.  239.— Cretinism.  Same  case.  Age 
9  years.  Height  .37%  inches,  gain  41/^ 
inches.     Front  view. 


Fig.  240.— Cvtatinism.  Same  case.  Age 
9  years.  Height  37%  inches,  gain  4% 
inches.     Baclv   view. 


She  cut  hor  i)iolKor  teeth  at  3  years  of  aije  and  the  rest  at  4  years.  She  has 
never  had  convulsions  or  any  other  sickness  except  measles  when  4  years  of  aofo. 
She  began  to  stand  on  her  feet  with  assistance  when  3  years  old.  She  did  not  speak 
a  word  until  5  years  old,  from  which  time  till  I  took  charge  of  her  she  could  say 
TU>  more  than  "papa"  and  "mamma." 

-  When  she  came  under  my  observation,  she  was  26  Va  inches  high.     She  weighed 


728 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


25  V3  pounds  and  was  quite  stout  in  proportion  to  her  height.  Her  head  was  large 
in  proportion  to  her  body.  The  lips  Avere  thick.  The  nose  flat  and  depressed  between 
the  eyes.  The  neck  was  very  short.  No  sign  of  enlarged  thyroid,  large  blue  eyes, 
teeth  in  fair  condition,  complexion  dark,  hair  dry  and  of  a  rusty  black  color.  ^ 


Fig.  241. — Cretinism.  Samu  ca-.-.  AgL 
11  years.  Height  39%  inches,  gain  2 
inches.     Front  view. 


Fig.  242.— Cretinism.  Same  case.  Age 
11  years.  Height  39%  inches,  gain  2 
inches.     Back  view. 


Hearing,  sight,  and  smell  apparently  good.  Voice  not  out  of  the  ordinary. 
The  extremities  were  short  and  thick,  lower  ones  were  bow-legged.  The  ends  of  the 
bones  were  large.  The  belly  was  larore  and  its  prominence  exaggerated  by  a  decided 
anterior  curvature  of  the  spine.      Intelligence  was  almost  nil,  temperament  very 


CRETINISM.  729 

irritable,  does  not  cry,  but  becomes  very  angry.  She  never  asks  for  food,  eats  little 
and  only  what  is  given  to  her.  The  bowels  were  constipated,  moving  only  once  in 
two  days.  She  never  asks  to  pass  stool  or  water.  Had  external  haemorrhoids,  which 
bled  occasionally.  When  awake  was  constantly  sitting.  Cannot  walk  alone  and 
only  a  few  steps  when  assisted.     She  slept  well.     Pulse  was  96  and  regular. 

Has  had  no  treatment  for  three  years.  Previous  to  this  time  parents  had  hetta 
all  over  with  her  and  tried  everything  suggested,  without  avail. 

On  January  25,  1897,  I  put  her  on  3  grains,  once  a  day,  of  desiccated  thyroids 
(Parke,  Davis  &  Co.).  On  February  18th  dose  was  increased  to  4  grains  daily,  but 
after  a  week  the  dose  had  to  be  reduced  to  2  grains,  as  the  pulse  rose  to  120  and  the 
chUd  became  irritable.  Otherwise,  some  improvement  was  already  noted  in  her 
general  condition;  she  could  stand  better  and  moved  her  bowels  daily.  After  anotlier 
week  (March  6th)  the  dose  was  increased  again  to  3  gi-ains  daily  and  was  continued 
so  till  I  saw  her  on  March  21st,  when  I  found  her  pulse  144,  strong  and  bounding. 
She  had  become  considerably  thinner,  having  lost  1  V2  pounds  in  weight  in  spite  of 
the  fact  that  she  had  gained  2  inches  in  height.  This  gave  her  a  much  more  natural 
appearance.  She  also  had  a  more  intelligent  facial  expression,  talked  mere  and 
decidedly  better,  walked  a  short  distance  M'ithout  assistance,  and  ate  better. 

On  account  of' the  accelerated,  pulse  and  loss  of  flesh,  I  decreased  the  thyroids 
again  to  2  grains  daily.  From  this  time  on  there  was  a  gradual  improvement  in  all 
the  symptoms.  By  the  middle  of  April  she  was  running  about  the  streets,  playing 
with  other  children,  and  asked  for  her  food.  In  May  she  began  to  tell  when  she 
wanted  to  move  her  bowels,  gradually  gained  in  intelligence,  spoke  more  and  articu- 
lated better.  The  dose  of  the  thyroids  was  gradually  increased  until  she  A^'a'fe  taking 
5  grains  daily  (July),  which  she  continued  for  more  than  a  year  and  a  half  without 
any  symptoms  of  intoxication. 

I  had  the  honor  of  presenting  her  before  the  Society'^  in  1898  after  one  year's 
treatment,  when  she  had  gained  6  V*  inches  in  height.  The  privilege  was  accorded 
me  again  in  1899  when  she  had  gained  an  additional  4  V2  inches.  The  average  growth 
of  a  normal  child  of  her  age  is  less  than  2  inches  a  year.  SJie  had  gained  over 
eleven  (11)  inches  in  tioo  year's. 

As  interesting  as  this  case  is  so  far,  the  most  significant  and  interesting  part  of 
it  comes  now.  I  lost  track  of  the  patient  in  January,  1899,  and  she  took  no  medicine 
from  that  time  until  I  saw  her  again  in  December,  almost  a  year  later.  My  note- 
book records  the  fact  that  there  was  no  increase  in  height  and  that  her  general 
appearance  was  not  good.  Although  I  ordered  the  thyroid  extract  it  was  not  given 
again  until  I  saw  the  patient  one-half  year  later,  on  June  1st,  1900,  and  again  there 
was  no  increase  in  height  or  improvement  in  general  condition.  The  patient's  next 
visit  was  in  February,  1901,  when  she  reported  that  5  grains  of  the  thyroid  had  been 
given  daily  from  June  1st  to  December  24th.  Measurement  showed  a  gain  of  2  inches 
in  height  ( 39  V2 )  •  Her  general  appearance  was  much  better  and  she  had  been  going 
to  school  for  a  few  weeks. 

If  any  proof  be  necessary  as  to  the  efficacy  of  the  thjToid  principle  in  cretinism, 
or  as  to  the  thyroid  gland  and  its  secretion  being  essential  to  the  proper  physiological 
workings  of  the  human  body,  the  history  of  this  case  supplies  it.  Take  the  one 
symptom  of  stature.  From  1  to  7  years  of  age,  Avithout  the  administration  of 
thyroids,  there  was  no  increase.  From  7  to  8  years,  with  thyroids,  there  was  a 
growth  of  6  V<  inches.  From  8  to  9  years,  also  Avith  thyroids,  there  Avas  a  growth  of 
4 'A  inches.     From  9  to  10  years,  without  any  thyroids,  there  was  no  growth.     From 


*  Eastern  Medical  Society,  New  York  City. 


730  DISEASES  OF  THE  DUCTLESS  GLANDS. 

10  Va  to  11  years,  with  thyroids  again,  2  inches  were  gained-  All  other  manifesta- 
tions of  this  cretinic  condition  underwent  corresponding  fluctuations  with  the  ad- 
ministration of  the  extract,  but  changes  in  stature  being  the  most  evident,  serve 
best  to  illustrate  the  progress  of  the  case. 

To  contrast  her  previous  with  her  present  condition  as  well  as  to  show  her 
appearance  during  the  period  of  her  improvement  no  better  means  could  be  utilized 
than  the  accompanying  photos.  The  first  pair  was  taken  in  February,  1897,  the 
second  in  1898,  the  third  in  1899,  and  the  fourth  in  February,  1901. 

She  is  now  sufficiently  intelligent  to  go  to  school.  She  plays  as  a  child  should 
and  her  general  health  is  very  good.  She  has  yet  the  physical  marks  of  her  previous 
condition  in  the  peculiar  features,  the  short  neck,  and  the  spinal  curvature  with 
the  abdominal  prominence,  though  they  have  all' improved,  especially  the  spine  and  the 
abdomen.  Her  height  is  about  12  inches  short  of  what  it  should  be  at  her  age,  11 
years,  but  if  the  rapid  rate  of  growth  continues  she  will  gain  a  good  part  of  it. 

September,  1901. — Has  taken  little  medicine.      Height  about  the  same. 

April  27,  1902. — Has  taken  medicine  one  and  one-half  months  sincei  last  visit. 
Height,  41  Vi  inches ;    goes  to  school. 

September  4,  1902. — Has  taken  5  grains  daily  since  April  27th.  Looking  and 
feeling  well.  Losing  flesh,  feels  cold  at  night,  hands  tremble  when  taking  things  to 
mouth  since  six  weeks.  Pulse,  188.  Height,  41  V2  inches.  Discontinued  thyroids 
three  weeks. 

I  saw  case  on  December  20^  1902.  No  thyroids  since  last  week.  Patient  is 
gaining  flesh,  shivering  (trembling)  stopped.  Pulse,  72.  Goes  to  school,  has 
mastered  her  figures  only,  (is  almost  13  years  old).  Ordered  2  V2  grains  thyi'oid 
daily. 

When  last  seen,  April  20,  1904,  the  mother  stated  the  girl  had  been  going  to 
school  for  the  last  two  years.  Very  little  mental  progress  has  been  made  during  this 
time.  She  reads  an  elementary  primer  and  can  remember  figures.  Has  taken  thyroid 
but  four  months  out  of  the  last  sixteen  months.  Her  height  is  43  V4  inches.  She 
has  gained  in  the  last  sixteen  months  about  two  inches.     Her  pulse-rate  is  72. 

Progfnosis  and  Course. — The  sooner  treatment  is  instituted  the  better 
the  result.  When  this  condition  is  neglected,  children  become  worse  and 
worse  until  finally  they  are  beyond  medical  aid. 

It  must  be  borne  in  mind  that  thyroid  must  be  given  for  years  if  last- 
ing results  are  to  be  obtained.  Children  will  go  backward  at  once  if  we 
discontinue  our  treatment,  even  though  the  same  has  been  continued  for 
some  years.  An  interesting  study  is  the  continuous  growth  including  men- 
tal development  plainly  seen  in  the  illustrations  of  cases  in  this  chapter. 

Treatment. — The  most  important  part  of  the  treatment  consists  in 
administering  from  1  to  5  grains  of  the  dessiccated  extract  of  thyroid. 
This  replaces  the  active  priiiciple  of  the  normal  thyroid  gland.  I  have 
used  with  very  good  success  thyroidin,  from  ^/g  to  2  grains  three  times  a 
day,  with  equally  good  result. 

Great  care  should  be  taken  to  watch  the  pulse-rate  while  giving  thy- 
roid. The  pulse  will  sometimes  increase  from  twenty  to  forty  beats  after 
the  administration  of  1  or  2  grains  of  thyroid.  The  moment  we  find  an 
exaggerated  pulse-rate,  it  will  be  necessary  to  reduce  the  dose  of  thyroid 


EXOPHTHALMIC  GOITEK.  73I 

* 
at  least  one-half.     A  flabby,  fat  child  will  at  once  lose  weight,  and  an  impor- 
tant feature  of  successful  treatment  is  an  increase  in  height. 

Thyroid  Iniplanldtion. — Implantation  of  sheep's  or  lamb's  thyroid 
(heterogeneous),  or  from  the  human  being  (homothyroid),  has  been  advo- 
cated by  some.  In  one  case  of  mine,  operated  by  Dr.  Howard  Lilienthal, 
the  implantation  of  lamb's  thyroid  was  tried.  Several  pieces  were  im- 
planted in  the  peritoneal  cavity.     Some  improvement  was  noted. 

We  must  not,  however,  blindfold  ourselves  to  the  belief  that  when  we 
supply  the  missing  internal  secretion,  namely,  thyroid,  that  we  have  ful- 
filled all  indications. 

The  diet  must  be  regulated  and  the  child  given  a  large  portion  of  pro- 
teids — milk,  meat  or  meat  extracts,  fresh  beef  blood  or  roast  beef  juice, 
orange  juice,  fresh  eggs,  and  all  cereals  must  be  given  as  body  builders. 
Fresh  air  and  a  general  attention  to  the  hj^gienic  condition  of  the  child  are 
very  important.  Massage,  gymnastics,  and  exercise  should  not  be  over- 
looked. 

If  the  appetite  is  poor  1  to  2-minim  doses  of  the  tincture  of  nux  vomica 
will  do  good.    Butter  and  codliver-oil  are  valuable  adjuncts. 

Exophthalmic  Goiter  (Htperthyrea_,  Basedow's  Disease, 
Graves's  Disease). 

This  disease  has  occasionally  been  seen  in  children.  It  is  supposed  to 
be  due  to  a  hypersecretion  of  the  thyroid  gland.  Sachs  believes  that  hered- 
ity is  a  more  important  factor  than  excitement  or  fright.  Epileptic  and 
alcoholic  parents  certainl}^  predispose  to  this  condition  in  children. 

Symptoms  and  Diagnosis. — There  are  three  symptoms  of  importance 
which  should  be  noted  : — 

1.  The  enlargement  of  the  thyroid. 

2.  Palpitation  of  the  heart  (tachycardia). 

3.  Protrusion  of  the  eyeballs  (exophthalmus). 

The  blood  tension,  is  increased,  hence  hemorrhages  from  the  nose, 
stomach,  or  intestines  are  quite  common.  Disturbances  of  vision  due  to  the 
exophthalmus  are  never  described.  The  thyroid  enlargement  is  usually 
bilateral.  Muscular  tremors  are  also  noted.  The  diagnosis  is  easily  made  by 
recognizing  the  symptoms  above  described.  There  is  a  physiological  hyper- 
aemia  of  the  thyroid  which  is  entirely  different  from  goiter. 

Prognosis. — Cases  seen  by  me  have  all  assumed  a  chronic  tendency.  I 
have  never  known  death  to  occur  directly  from  this  condition.  When  death 
occurred  it  was  due  to  some  complication. 

Treatment. — Spartein  sulphate,  strophanthus,  digitalis  or  belladonna 
combined  with  iodide  of  sodium  may  be  tried.  The  galvanic  current  is 
strongly  advised  by  some  writers.      Recently  x-ray  treatment  has  been 


732  DISEASES  OF  THE  DUCTLESS  GLANDS. 

used  in  conjunction  with  the  above-mentioned  drugs.  The  danger  of 
x-ray  dermatitis  should  be  remembered  by  those  having  little  experience 
with  light  treatment. 

The  use  of  thyroid  has  been  suggested,  but  it  has  failed  to  do  good  in 
my  hands. 

t  Acute  Thyroiditis. 

Inflammatory  conditioEs  such  as  abscess  have  been  described  as  a  com- 
plication of  the  infectious  diseases.  The  migration  of  streptococci  or  other 
pyogenic  bacteria  may  give  rise  to  suppurative  inflammation.  The  treat- 
ment is  surgical. 

Abnormality  or  the  Thyroid. 

Syphilitic  gummata  and  tuberculosis  have  been  found  in  rare  instances. 
Malignant  disease  involving  the  thyroid  has  been  reported  among  infantile 
disorders. 

Diseases  of  the  Adrenal  Glands. 

Pathologists  have  frequently  described  hgemorrhages  into  the  adrenal 
glands  in  the  new-bom  infant.  Diseases  -per  se,  excepting  cancer,  have  not 
been  described.  There  is  still  considerable  to  be  learned  concerning  tlie 
physiology  of  these  glands. 

Addison's  Disease. 

This  rare  condition  is  occasionally  described.  Literature  records  about 
twenty  cases  in  all. 

Symptoms. — The  symptoms  of  the  disease  consist  of  a  deep-yellowish 
or  bronzed  pigmentation  of  the  skin.  It  is  found  on  the  exposed  parts  of 
the  body,  such  as  the  hands  and  head.  The  mucous  membranes  of  the 
mouth  and  vagina  are  also  pigmented.  White  areas  of  skin  are  scattered 
over  the  body.  Vomiting,  diarrhoea,  and  nervous  symptoms  are  noted. 
Anaemia  is  usually  very  marked. 

Diagnosis. — In  the  diagnosis  of  this  condition  it  is  necessary  to  exclude 
pigmentation  of  the  skin  due  to  metallic  poisons,  such  as  argj^ria,  from  the 
internal  administration  of  nitrate  of  silver.  Arsenic  and  lead  have  been 
reported  as  causative  factors  of  bronzed  skin. 

Prognosis. — ^While  most  authors  report  the  outcome  as  fatal,  some  few 
recoveries  have  been  noted.  In  a  case  seen  by  me  recovery  took  place  after 
several  years  of  treatment. 

Treatment. — We  have  no  specific  treatment  for  this  condition.  Some 
authors  advise  the  administration  of  the  raw  or  cooked  adrenal  glands  of 
the  sheep.  The  dry  extract  in  tablet  form  has  been  isolated  and  1-grain 
doses  of  this  extract  may  be  given  three  times  a  day.  When  the  gland 
itself  is  used,  one-half  to  one  gland  may  be  given  in  twenty-four  hours. 

The  value  of  hygienic  and  dietetic  measures  I  regard  as  more  impor- 
tant than  medication. 


PART  IX. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 


CHAPTEE  I. 
FONTANEL. 


The  posterior  fontanel  is  usually  closed  at  the  end  of  the  second  month. 
The  anterior  fontanel  normally  closes  between  the  sixteenth  and  twentieth 
months.  If  the  fontanel  is  open  at  the  end  of  the  second  year,  then  rickets 
or  other  abnormality  may  be  considered.  A  fullness  of  the  anterior  fontanel 
and  bulging  of  the  same  at  the  end  of  the  second  year  is  pathological.  (See 
chapter  on  "Hydrocephalus.")  Premature  closure  of  the  fontanel  fre- 
quently occurs  in  microcephalus  and  also  in  congenital  idiocy.  This  prema- 
ture closing  interferes  with  the  proper  growth  and  development  of  the  brain. 

Shape  of  the  Head. — Peculiar  shapes  of  the  head  are  met  with  unde' 
perfectly  normal  conditions.  An  interesting  study  is  the  series  of  outline 
sketches  of  the  head  which  show  the  modifications  in  form  produced  'by 
labor  and  also  the  normal  sketches  of  the  head.  , 

Circumference. — The  average  circumference  of  the  head  at  birth  in  446 
full-term  infants  taken  in  about  equal  numbers  from  the  Sloane  Maternity 
Hospital  and  New  York  Infant  Asylum,  quoted  by  Holt,  was  as  follows: — 

Average  circumference  of  the  head,  231  males..    13.90  inches   (35.5  centimeters) 

Average  circximference  of  the  head,  251  females    13.52  inches   (34.5  centimeters^ 

Total 446  infants.  13.71  inches   (35.0   centimeters) 

Auscultation  of  the  Anterior  Fontanel. — A  bruit  is  occasionally  heard 
over  the  anterior  fontanel.  (Plates  XXXIY,  XXXV.)  It  is  a  blowing 
sound  similar  to  that  heard  in  the  vessels  of  the  neck  during  anaemia  or  in 
oblorotic  girls.  I  have  described  this  condition  in  the  chapter  on  "Eachitis.'' 

Percussion  of  the  Skull. 

MacEwen,  in  his  treatise  upon  the  pyogenic  infective  diseases  of  the 
brain  and  spinal  cord,  says :  "When  the  lateral  ventricles  are  distended  with 
serous  fluid,  as  would  be  occasioned  by  cerebral  tumors  pressing  on  the 
fourth  ventricle,  or  by  occlusion  of  the  veins  of  Galen  or  otherwise,  the  per- 
cussion note  is  markedly  altered,  the  resonance  being  greatly  increased. 

(733) 


'j'34  Diseases  of  ^fiii  nervous  sysMM. 

OuTUNE  Sketches  of  the  Head,  Showing  the  Vaeious  Diametees. 


Fig.  243. — Sagittal,  Section  of 
Normal  Head  of  Seven  and  One-half 
Months'  Foetus,  Half  Natural  Size. 
(After  Ballantyne.) 


Fig.  244. — ^Normal  Head  as  Seen 
from  Above,  Half  Natural  Size. 
(After  Budin.) 


Fig.  245.— Sagittal  Section  of  Nor- 
mal Head,  Half  Natural  Size. 
(After  Budin.) 


Fig.  246.— Sagittal  Section  of 
Head  Immediately  After  Normal, 
Easy  Labor,  Half  Natural  Size. 
(After  Ballantyne.) 


Besides  the  increased  resonance,  there  is  an  important  feature  which  may  be 
demonstrated :  The  percussion  elicited  at  a  given  spot  on  the  cranium,  such 
as  the  pterion,  varies  according  to  the  position  of  the  head.  AVhile  the  per- 
son sits  with  the  head  upright,  the  most  resonant  note  is  brought  out  by 
percussion  toward  the  basal  level  of  the  frontal  bones  and  the  squamous 


OUTLINE  SKETCHES  OP  THE  HEAD. 


735 


OuTUNE  Sketches  of  Head  of  Infant,  Showing  the  Modifications  in 
Form  Produced  by  Labor,  etc. 


Fig.  247. — Sagittal  Sec- 
tion of  Head  Immediately 
After  Labor  (0.  D.  P. 
Position).  (After  Bal- 
lantyne. ) 


Fig.  248. — Sagittal  Sec- 
tion of  Head  Immediately 
After  Labor,  Half  Nat- 
ural Size  (O.  D.  P.  Posi- 
tion).     (After  Budin.) 


Fig.  249.— Sagittal  Sec- 
tion of  Head  of  Infant  Six 
Days  Old,  Half  Natural 
Size.       (After    Ballantyne.) 


•^36  DISEASES   OF   THE   KEHVOUS   SYSTEM. 

portion  of  the  parietal.  If  the  patient  hangs  his  head  to  one  side,  so  that 
one  parietal  is  placed  fairly  below  the  other,  the  greater  resonance  is  found 
on  percussion  of  the  lower  parietal.  Eeverse  the  position  and  the  same  note 
is  elicited  on  the  opposite  side  of  the  head,  which  is  now  the  lower,  the 
greater  resonance  being  found  at  that  part  of  the  skull  nearest  the  lateral 
ventricles,  and  which  for  the  time  is  at  the  lowest  level. 

"These  observations  tend  to  indicate  that  the  quality  of  this  note  is 
not  dependent  on  the  mere  density  of  the  diameter  of  the  cranium,  but  to 
a  large  extent  upon  the  consistence  or  arrangement  of  the  intercranial  con- 
tents relatively  to  the  osseous  walls.  .  .  .  The  exact  mechanical  quality 
of  the  note  is  difficult  to  describe,  but,  when  heard,  it  conveys  the  idea  of 
hollowness.  One  such  case,  in  which  the  above  phenomena  were  clearly 
marked,  was  observed  to  a  conclusion.  The  percussion  note  was  not  so  clear 
at  first  as  it  ultimately  became,  the  resonance  increasing  as  the  disease 
advanced. 

"In  tumors  of  the  cerebellum  it  is  an  aid  to  diagnosis,  and  when  present 
with  abscess  it  points  to  an  involvement  of  the  cerebral  fossa." 

The  Beain.^ 

In  the  new-bom  the  dura  mater  is  closely  adherent  to  the  skull,  so  that 
extravasations  between  the  dura  mater  and  the  skull  are  unknown. 

Fluid  in  the  Subarachnoid  Space. — In  infancy  and  childhood  more 
fluid  is  found  in  this  space  than  in  adult  life.  McClellan  believes  that 
"hydrocephalus  due  to  an  excessive  amount  of  fluids  in  the  ventricles  of  the 
brain  may  be  caused  by  the  closure  of  a  small  opening  in  the  pia  mater 
which  is  found  at  the  inferior  boundary  of  the  fourth  ventricle  known  as 
the  foramen  Magendie.^' 

Blood-vessels  of  the  pia  mater  are  so  delicate  that  blood  pressure,  trau- 
matism, etc.,  may  cause  haemorrhage  into  the  subarachnoid  space,  resulting 
in  monoplegia,  haemiplegia,  or  diplegia. 

Growth  and  Development  of  the  Brain. — From  birth  until  the  seventh 
year  is  reached  the  brain  grows  very  rapidly;  after  the  seventh  year  the 
growth  is  slow. 

Weight  of  the  Brain. — The  weight  of  the  brain  of  the  new-born  infant 
is  one-third  that  of  the  adult.  In  male  and  female  children  it  is  approxi- 
mately the  same  at  birth,  although  later  on  the  male  brain  grows  more 
rapidly  than  the  female.  When  a  child  is  between  7  and  8  years  of  age, 
the  brain  reaches  the  adult  size  and  weight.  There  is  from  this  time  on  a 
slight  increase  in  the  weight  up  to  the  twenty-fifth  year. 

Vierordt  states  that  the  increase  of  the  brain  after  the  seventh  year  is 

^  The  development  of  the  senses  is  described  in  Part  I,  chapter  on  the  "New-born 
Infant." 


PLATE  XXXIV 


Tront  View  of  tlio  F(Pt;il    Skull,    showing   the   antorior   foiitaiiollo   ami   the 
coronal    and    frontal    suture:*.      (Grandin    &    Jarman.) 


PLATE  XXXV 


Top   View    of   the    Foetal    Skull,    showing   the    anterior    fontanelle    and    the 
frontal,  coronal,  and  sagittal  sutures.      (Grandin  &  Jarman.) 


PLATE  XXXVI 


Posterior  View  of  the  F(¥tal  Skull,  showing  the  posterior  fontanelle  and  the 
lambdoidal  and  sagittal  sutures.      (Grandin  &  Jarman.) 


REFLEXES.  737 

due  to  an  increase  in  the  thickness  of  the  cortex  and  in  the  size  of  the 
cortical  constituents. 

Difference  Between  Infantile  and  Adult  Brain. — The  fissure  of  Sylvius 
in  its  relation  to  the  spherio-parietal  and  squamous  sutures  occupies  a 
higher  position  in  childhood  than  in  later  life,  Symington  and  McCkdlan, 
in  studying  frozen  sections  of  the  brain  of  children  under  7  years  of  age, 
found  the  Sylvian  fissure  above  the  squamous  suture  and  covered  by  the 
parietal  bone. 

Fissure  of  Rolando. — The  position  is  the  same  in  the  infant  as  in  the 
adult. 

The  Cerebellum. — This  is  much  smaller  in  the  child  than  in  the  adult 
in  comparison  with  the  cerebrum. 

The  convolutions  of  Uie  brain  are  more  shallow  in  the  infant  than  in 
the  adult.  The  depressions  or  sulci  between  the  convolutions  are  not  so 
deep  in  the  infant  as  in  later  life.  The  special  centers  of  the  brain  are  not 
fully  developed  in  the  infant  (Taylor  and  Wells). 

Eeflexes. 

Excess  of  Reflex  Action. — In  acute  mania,  in  cerebritis,  and  in  acute 
meningitis  we  have  excessive  reflex  action.  In  chronic  hemiplegia  an  in- 
crease of  the  reflexes  associated  with  ankle  clonus  is  found  on  the  affected 
side.  In  hydrophobia,  transverse  myelitis,  insular  sclerosis,  and  in  tetanus 
we  have  an  exaggeration  of  superficial  and  deep  reflexes.  Attention  is 
directed  to  the  chapters  on  "Tubercular  Meningitis"  and  "Epidemic  Cerebro- 
spinal Meningitis"  for  clinical  illustrations  of  the  reflexes. 

Diminution  of  Reflex  Action. — The  reflexes  axe  lessened  and  sometimes 
absent  in  melancholia.  Extreme  pressure  in  the  cranial  cavity  or  in  the 
spinal  canal  will  reduce  the  reflex  act.  Whenever  a  degeneration  of  mus- 
cles or  nerves  takes  place,  such  as  in  diphtheria  or  other  speciflc  diseases,  the 
reflexes  will  be  lessened.  The  reflex  is  reduced  or  wanting  in  acute  anterior 
poliomyelitis. 

BahinsTci  Reflex. — In  the  new-born  baby  this  reflex  has  frequently  been 
noted  under  normal  conditions.  Instead  of  normal  flexion  of  the  toes, 
which  is  accomplished  by  irritation  of  the  soles  of  the  feet,  we  have  in  dis- 
ease a  hyperextension  of  the  great  toe.  This  symptom  is  regarded  as 
pathognomonic  by  some  authors.  I  have  frequently  found  this  symptom 
present  in  tuberculous  meningitis^  and  regarded  it  as  a  valuable  diagnostic 
aid.     (See  clinical  case,  article  on  "Tubercular  Meningitis.") 

Reaction  of  Degeneration. — "In  health  a  faradic  current  of  sufficient 
strength  applied  to  the  nerve  produces  a  continuous  contraction  of  the  mus- 
cle; the  galvanic,  a  momentary  contraction  when  the  current  is  made  and 
broken  only.     When  the  nerve  is  diseased  a  stronger  faradic  or  galvanic 

41 


738  DISEASES   OF   THE    NERVOUS    SYSTEM. 

current  is  needed  to  produce  contraction,  until  finally,  when  degeneration 
has  taken  place,  no  current  which  can  be  used  produces  any  contraction. 
In  health  either  current  applied  to  the  muscle  produces  contraction;  the 
response  both  to  the  galvanic  current  and  to  the  f aradic  is  quick,  being  in 
both  instances  due  to  stimulation  of  the  nerve-endings.  With  lesion  of  the 
nerve  and  consequent  degeneration  of  the  nerve-endings,  the  faradic  cur- 
rent produces  no  contraction,  but  since  the  galvanic  current  is  capable  also 
of  stimulating  the  muscle  fibers  themselves,  a  contraction  follows  appli- 
cation, though  more  slowly  than  when  the  nerve-endings  are  healthy.  After 
the  degeneration  has  progressed  to  a  certain  stage,  which  is  reached  the 
earlier  the  more  severe  the  case,  this  response  of  the  muscle  fibers  to  the 
galvanic  current  becomes  more  ready  than  in  health.  To  this  quantitative 
change  is  added  a  qualitative  change.  In  health,  the  weakest  galvanic  cur- 
rent which  causes  contraction  of  the  muscle  does  so  when  the  current  is 
made  with  the  negative  pole  on  the  muscle  (kathode  closure  contraction, 
K.  C.  C).  When  the  nervous  mechanism  has  degenerated  a  contraction 
may  occur  with  as  weak  or  with  a  weaker  current  when  the  positive  pole  is 
on  the  muscle  (anode  closure  contraction,  A.  C.  C),  and  contractions  may 
occur  also  with  the  same  current  when  it  is  broken  (anode  opening  contrac- 
tion, A.  0,  C,  and  kathode  opening  contraction,  K.  0.  C.^).  To  this 
altered  qualitative  and  quantitative  reaction  of  nerve  and  muscle  to  the 
electric  currents  the  term  "reaction  of  degeneration"  is  applied.  It  is  not 
always  as  definitely  marked  as  is  above  described.  When  the  damage  to 
the  nerve  is  slight,  the  irritability  of  the  nerve  to  both  currents  may  be 
retained,  and  the  only  evidence  of  the  existence  of  a  reaction  of  degenera- 
tion is  increased  muscular  irritability  to  the  galvanic  current,  with  some 
change  also  in  the  order  of  contraction  to  the  poles  (qualitative  change). 
On  the  other  hand,  in  very  chronic  changes  the  loss  of  irritability  proceeds 
pari  passu  in  nerve  and  muscle,  and  the  reaction  of  degeneration  is  not  to 
be  observed. 

"With  the  regeneration  of  the  nerve,  recovery  of  function  takes  place, 
the  rate  of  recovery  depending  mainly  on  the  severity  of  the  lesion.  Vol- 
untary power  is  first  regained,  then  the  galvanic  reactions  become  normal, 
and  lastly,  the  faradic. 

"Anaesthesia,  which  is  the  eventful  result  of  degeneration  of  a  sensory 
nerve,  may  be  preceded  by  a  condition  of  hypergesthesia.  The  anaesthesia  is 
often  incomplete,  especially  in  the  hands  and  face;  in  a  mixed  nerve  a 
lesion,  capable  of  producing  paralysis  of  motion,  may  be  accompanied  by 
little  loss  of  sensation.  Trophic  changes  seem  seldom  to  occur  in  children 
as  an  accompaniment  of  lesions  of  sensory  nerves.^' 


•The  normal  order  is:      K.C.C.,  A.C.C.,  A.O.C.,  K.0.0. 


CHAPTER  II. 

CONVULSIONS  (ECLAMPSIA). 

Convulsions  occur  mostly  in  infancy.  After  the  seventh  year  of  life 
they  are  very  rare.  The  brain  grows  more  during  the  first  year  than  in  all 
later  life.  This  rapidity  of  growth  is  in  itself,  according  to  some  writers, 
an  important  predisposing  cause  of  functional  derangement. 

Etiology. — The  Exciting  Causes. — The  predisposing  causes  may  be 
grouped  under  the  name  of  "central."     They  are: — 

1.  Diseases  having  a  high  temperature. 
•  2.  Diseases  accompanied  by  vascular  stasis. 

3.  Diseases  characterized  by  anaemia  and  exhaustion. 

4.  Toxic  causes. 

5.  Organic  central  lesions. 

6.  Functional  disturbances  of  the  brain,  such  as  epilepsy. 

Of  all  the  manifold  predisposing  causes  of  convulsions  in  young  chil- 
dren, the  most  important  one  is  the  natural  instability  of  the  nervous  cen- 
ters, characteristic  of  early  life,  and  associated  with  the  non-development  of 
voluntary  centers  of  the  cortex;  hence  it  is  that  age  is  a  most  important 
factor  in  the  etiology  of  convulsions;  and  under  2  years  is  recognized  as 
by  far  the  most  susceptible  period.  Statistics  show  that  over  60  per  cent. 
of  deaths  from  convulsions,  up  to  20  years,  occur  in  infants  under  1  year 
of  age.  Convulsions  are  not  only  more  common  in  infancy,  but  much 
more  fatal  than  later  in  life,  and  for  reasons  that  are  very  apparent.  It 
has  been  stated  by  some  good  observers  that  males  seem  to  be  more  suscep- 
tible than  females;  statistics  seem  to  justify  this  conclusion,  but  it  has 
been  suggested  by  others  that  inasmuch  as  more  males  than  females  are 
born  each  year,  the  larger  number  of  deaths  in  males  may  thus  be  recon- 
ciled, for  surely  it  would  be  contrary  to  reasonable  expectation,  as  females 
are  more  delicately  organized,  while  the  exciting  causes  are  probably  about 
equal. 

The  Peripheral  Causes. — The  peripheral  causes  are  rachitis;  gastric 
disturbances,  such  as  acute  catarrhal  gastritis ;  intestinal  worms :  foreign 
bodies  in  the  ear  and  nose,  causing  reflex  convulsions;  scalds  and  burns, 
and  mental  disturbances,  such  as  fright,  will  induce  convulsions.  Lewis 
says:  "Convulsions  are  in  all  probability  due  to  an  exaltation  of  the  hirer 
nerve-centers;  or  more  frequently,  to  a  suspension  of  the  inhibitory  power 
of  the  higher  cerebral  centers" — or  both  of  these  conditions  may  exist  at 

(739) 


'".■40  DISEASES    OF    THE    NERVOUS    SYSTEM. 

the  same  time — and  further,  "It  remains  to  be  said  that  we  are  still  very 
much  in  the  dark  as  to  the  immediate  processes  producing  convulsions." 

"Infants  have  their  nervous  system  in  process  of  rapid  development — 
only  the  component  but  undifferentiated  parts  of  which  are  in  great  activity, 
ready  to  receive  and  re-energize  limitless  new  impressions."  At  birth,  the 
lower  centers  only  are  developed,  and  control  is  limited  until  the  higher 
centers  become  competent  to  exert  inhibition;  hence  in  the  earlier  months  of 
life  convulsions  are  common,  and  less  so  after  two  years. 

Improper  feeding  may  be  looked  upon  as  the  most  frequent  cause  of 
convulsions.  A  child  that  is  improperly  fed  and  suffers  with  a  subacute  or 
chronic  form  of  dyspepsia,  suffers  with  a  deficient  structure.  Such  struc- 
tural weakness  resulting  in  rachitis,  is  a  cause  for  that  most  common  form 
of  spasm  known  as  laryngeal  spasm  and  tetany.  Toxemic  conditions  re- 
sulting from  bacterial  infection  are  a  most  frequent  cause  of  convulsion. 

Pathology. — The  development  of  the  nervous  system  is  not  complete 
at  birth.  Very  little  light  is  shed  upon  convulsions  by  post-mortem  findings. 
Usually  after  death  from  con-snilsions  there  is  an  effusion  or  haemorrhage 
found  or  there  is  a  venous  stasis  in  the  brain.  When  death  occurs  from 
laryngospasm  it  results  from  suffocation.  The  condition  of  the  brain  in 
the  beginning  of  an  attack  of  convulsion  is  one  of  anjemia.  This  is  shortly 
followed  by  a  nervous  hypersemia.  The  brain  and  meninges  are  usually 
found  intensely  congested  and  engorged.  Sometimes  punctate  haemorrhages 
can  be  found.  The  lungs  are  also  deeply  congested  and  the  right  heart  is 
generally  distended  with  dark  clots  (Holt). 

Symptoms. — There  is  usually  a  loss  of  consciousness.  The  "onset  is 
sudden.  A  child  may  appear  perfectly  well  up  to  the  time  of  its  convulsion 
and  then  suddenly  the  arms  and  legs  become  stiff,  the  eyes  -fixed  and  staring 
or  rolled  up  under  the  lids.  Eespiration  is  usually  arrested,  the  head  is 
retracted;  finally  the  whole  body  becomes  rigid. 

The  above  named  symptoms  belong  to  the  tonic  stage.  ■  It  is  usually 
followed  by  clonic  con^oilsions  more  or  less  severe  and  prolonged,  affecting 
the  upper  and  lower  limbs,  the  face  and  eyes. 

Sometimes  the  tonic  and  clonic  convulsions  are  few  and  the  whole 
spasm  may  last  less  than  a  minute.  Some  children  show  no  sign  of  illness 
after  the  attack  is  over,  and  appear  perfectly  normal.  The  attack  may  recur 
at  short  intervals.  The  child  may  then  become  comatose  and  die  before 
proper  treatment  can  be  instituted.  It  is  important  to  examine  the  urine. 
The  possibility  of  a  nephritis  should  not  be  overlooked. 

Diagnosis. — It  is  usually  very  simple  to  differentiate  from  epilepsy, 
which  is  most  frequent  after  the  third  year. 

Convulsions  usually  are  the  first  symptoms  of  the  invasion  of  an  acute 
disease.  Scarlet  fever,  pneumonia,  malaria,  gastritis,  and  meningitis'  may 
be  ushered  in  with  convulsions.    Measles  is  sometimes  preceded  by  convul- 


CONVULSIONS.  741 

sions.  Pertussis  in  which  there  is  cerebral  congestion  may  cause  convul- 
sions. Bronchitis,-  membranous  laryngitis,  and  laryngismus  stridulus  are 
sometimes  preceded  by  convulsions.  Do  not  suspect  teething  or  worms  as 
a  cause  of  convulsions  until  all  other  causes  have  been  eliminated. 

Treatment. — The  treatment  of  convulsions  consists  of  controlling  the 
spasm.  Inhalations  of  chloroform  or  sulphuric  ether  should  be  cautiously 
used,  regardless  of  the  age  of  the  infant,  until  convulsions  cease. 

Chloral  hydrate  and  bromide  of  sodium,  with  some  starch  water,  should 
be  injected  into  the  rectum;  5  grains  each  of  chloral  and  bromide  with  a 
tablespoonful  of  starch  water  should  be  used  and  repeated  every  hour  until 
the  spasms  are  controlled.  Leeching  by  the  application  of  one  or  two 
leeches  behind  the  ears  is  valuable  to  relieve  cerebral  congestion.  We  can 
also  drain  blood  from  the  frontal  sinus  by  the  application  of  one  or  two 
leeches  at  the  alas  nasi.  A  mustard  foot-bath  should  likewise  be  used  until 
hyperannia  of  the  skin  is  produced.  While  the  feet  are  suspended  in 
mustard  water  an  ice-bag  or  a  cold  cloth  shodd  be  applied  to  the  head. 

A  cliild,  4  years  old,  was  suddenly  seized  with  convulsions,  clonic  and  tonic 
spasms  involving  the  face,  arms,  and  legs.  From  the  history  I  learned  that  the 
cliild  had  overloaded  its  stomach,  was  very  feverish,  and  thirsty.  A  mustard  foot- 
bath was  ordered  and  a  rectal  injection  of: — 

IJ   Sodium   bromide     10  grains 

Chloral    hydrate  5  grains 

was  injected  into  the  rectum  with  two  tablespoonfuls  of  thin  starch  water. 

One  or  two   inhalations  of  chloroform  were  given   to   relieve  the   con^^llsions. 

The  diagnosis  of  acute  catarrhal  gastritis  was  made  and  the  convulsions 
attributed  to  a  general  toxaemia.  When  t!ie  convulsions  ceased  the  stomach  was 
washed  with  two  quarts  of  warm  water  to  which  two  tablespoonfuls  of  salt  had  been 
added.     Food  was  discontinued  and  an  interval  dose  of: — 

IJ   Sodium   bromide     5  grains 

Chloral  hydrate    2  grains 

was  given  every  hour  xmtil  the  child  was  in  a  deep  sleep.  Twelve  hours  after  the 
convulsions  first  began,  thin  soup  and  broth  were  ordered.  The  child  was  well  in 
two  days. 

To  control  convulsions : — 

IJ   Sodii  bromidi 5  grains 

Chloral    hydrate     5  grains 

Starch    water     1  tablespoonful 

Mix  thoroughly  and  inject,  if  possible,  into  the  colon,  through  a  small  rubber 
catheter.     Repeat  every  hour  until  convulsions  cease. 

Lumbar  puncture,  the  technique  of  which  I  describe  elsewhere,  is  one 
of  our  most  valuable  tberapeutic  measures.  By  withdrawing  20  to  30  cubic 
centimeters  of  cerebrospinal  fluid,  I  have  seen  marked  benefit  therefrom. 
The  intracranial  pressure  which  was  relieved  by  this  procedure,  lessened  the 


743  DISEASES  OF  THE  NERVOUS  SYSTEM. 

irritability  of  the  child  and  promoted  sleep.  In  a  case  of  auto-intoxication 
due  to  gastric  fever,  with  a  temperature  of  105°  Y.  and  over,  in  a  child 
about  eighteen  months  old  suffering  with,  continued  convulsions,  the  follow- 
ing order  of  treatment  was  carried  out :  First,  a  colonic  flushing  to  empty 
the  bowel ;  second,  a  tepid,  pack  over  the  thorax ;  third,  a  lumbar  puncture, 
withdrawing  about  35  cubic  centimeters  of  colorless  cerebrospinal  fluid; 
fourth,  a  diet  of  whey,  and  plenty  of  water  was  followed  by  an  amelioration 
of  all  the  symptoms. 

Headaches. 

Various  forms  of  headache  are  encountered  in  children.  As  a  rule 
very  little  reliance  can  be  placed  on  headaches  complained  of  by  young 
children.  There  are  four  kinds  of  headaches  which  are  most  frequently 
seen  in  older  children : — 

1.  Eeflex  headache. 

3.  Headache  due  to  general  systemic  cause. 

3.  Headache  of  local  origin. 

4.  Headache  due  to  brain  lesions. 

Reflex  Headache. — In  chlorotic  girls  or  in  anaemic  children  headache 
is  a  common  symptom.  During  menstrual  disorders  girls  will  usually  com- 
plain of  headaches. 

Hundreds  of  cases  of  headache  due  to  eye  strain  have  been  seen  bv 
me  in  school  children.  These  children  complain  of  headache  during  and 
after  school  hours.  The  headache  disappears  during  the  night  and  the 
children  never  complain  of  headache  in  the  morning.  Most  of  these  cases 
have  been  referred  by  me  to  an  oculist,  who  as  a  rule  finds  astigmatism. 
The  treatment  consists  in  relieving  the  eye  strain  by  wearing  eyeglasss. 

Headache  Due  to  General  Systemic  Causes. — Headache  due  to  auto- 
intoxication resulting  from  impacted  faeces  is  frequently  encountered. 
Eheumatic  children  and  children  of  gouty  parents  frequently  complain  of 
headaches.  Such  headaches  are  frequently  found  in  lithsemia.  The  gen- 
eral constitutional  treatment  consists  of  a  diet  of  vegetables,  and  fruit. 
No  meat  should  be  given.  Five  to  15  grains  of  citrate  of  potash  will 
usually  benefit  this  condition.  A  laxative  should  always  be  given  if  head- 
ache is  due  to  constipation.  Exercise  and  outdoor  play  will  aid  this 
condition. 

Headache  Due  to  Local  Origin. — Children  frequently  complain  of 
headache  which  is  due  to  intra-nasal  neoplasms.  At  other  times  such  local 
causes  as  supra-orbital  neuralgia,  due  to  neuralgia  of  the  fifth  cranial 
nerve,  will  cause  an  intense  headache.  In  the  latter  instance  gentle  mas- 
sage or  a  mild  current  of  faradic  electricity  will  relieve.  In  severe  cases  the 
internal  administration  of  Vsoo  grain  of  Duquesnel's  aconitia,  three  times 
a  day,  will  relieve,     In  persistent  headache  it  is  advisable  to  have  the  ears 


SPASMUS   NUTANS.  743 

carefully  examined  by  a  competent  aurist.     The  frequency  of  middle-ear 
disease  should  be  borne  in  mind. 

Headache  Due  to  Brain  Lesions. — In  older  children  headache  of  a 
persistent  character,  associated  with  vomiting,  should  always  be  looked 
upon  as  suspicious  of  cerebral  trouble.  A  case  of  this  kind  is  reported  by 
me  in  the  chapter  on  "Cerebro-spinal  Meningitis.^^  In  older  children  suf- 
fering with  persistent  headache  it  is  advisable  to  examine  the  fundus  of 
the  eye  to  see  if  a  choked  disc  is  present.  In  one  of  my  cases  a  tumor  of 
the  cerebellum  was  diagnosed  in  this  manner. 

Migraine  (Sick  Headache:  Hemicrania). 

This  is  a  headache  confined  to  one  side  of  the  head,  associated  with 
dizziness  and  generally  vomiting. 

Causes. — Overworked  school  children  of  a  nervous  type  usually  have 
these  attacks.  Children  suffering  with  dyspeptic  attacks  are  more  fre- 
quently the  victims  of  migraine.  An  indoor  life  in  a  crowded  apartment 
will  cause  this  condition.    Eye  strain  is  frequently  the  cause. 

Treatment. — Have  the  eyes  examined  and  correct  any  abnormality,  if 
present.  The  diet  should  be  regulated  and  a  laxative  dose  10  to  20  grains 
of  phosphate  of  soda  should  be  given.  The  value  of  bromide  of  soda  in 
Seltzer  water,  with  or  without  caffeine,  should  be  remembered. 

Spasmus  Nutans. 

This  condition  is  frequently  associated  with  rickets.  It  is  characterized 
by  an  involuntary  and  uncontrollable  head  shake. 

Etiology. — It  may  be  associated  with  or  follow  traumatism.  Fright 
and  other  psychical  disturbances  may  cause  this  condition.  Heredity  plays 
an  important  part  in  its  development.  It  is  usually  found  associated  with 
rickets.  In  a  case  of  mine  presented  to  the  Section  on  Pediatrics  of  the 
New  York  Academy  of  Medicine,^  spasmus  nutans  was  associated  with 
sporadic  cretinism. 

Symptoms. — In  some  cases  we  see  a  continuous  nodding,  in  other  cases 
the  motion  is  rotary.  In  rare  cases  both  motions,  nodding  and  rotary,  may 
co-exist.  Nystagmus,  which  is  a  movement  of  the  eyes,  rhythmical  and 
oscillatory,  either  vertical  or  horizontal,  may  also  be  present. 

Prognosis. — This  depends  on  the  cause  of  the  same.  As  a  rule  the 
prognosis  is  good. 

Treatment. — If  rickets  is  the  cause  give  the  child  anti-rachitic  treat- 
ment. If  it  is  associated  with  cretinism,  as  in  the  case  reported  by  me, 
then  give  thyroid  treatment.    A  change  of  air  and  general  restorative  treat- 


'§ee  Proceedings  of  New  York  Academy  of  Medicine  fof  1904. 


744  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ment  are  also  beneficial  in  these  cases.     Electricity  is  not  indicated  and 
should  not  be  used.    Massage  may  be  tried. 

Speech  Defects, 

Stuttering. — ^This  is  a  condition  due  to  a  series  of  contractions  and 
spasms  of  the  muscles  concerned  in  speech.  According  to  Scripture,  the 
essential  pathological  fact  is  a  special  state  of  mind. 

Pseudo-stuttering. — ^This  symptom  is  found  in  hysteria,  cerebral  spastic- 
ity, athetotic  conditions,  aphasia,  and  some  forms  of  amyotrophic  lateral 
sclerosis. 

Lisping. — There  are  various  types  of  lisping.  Organic  lisping  is 
caused  by  a  defect  in  the  teeth,  tongue,  palate  or  ears.  We  may  have 
negligent  lisping  due  to  a  faulty  perception  and  execution  of  sounds.  This 
condition  may  be  found  in  normal  children  as  well  as  in  those  of  deficient 
mentality.  The  necessity  for  proper  medical  supervision  in  the  treatment 
of  this  class  of  cases  is  forcibly  expressed  by  Scripture,^  who  maintains  that 
the  speech  organs  must  be  examined  by  a  physician  familiar  with  the  anat- 
omy of  the  nose,  throat,  and  larynx.  In  addition  thereto,  neurological 
training  is  necessary  for  a  proper  understanding  of  stuttering.  Such  cases 
should  be  sent  to  a  proper  clinic,  where  speech  defectives  can  be  classified 
according  to  their  individual  defects. 

Choeea  (St.  Vitus'  Dance). 

This  is  a  neurosis  characterized  by  irregular,  involuntary  movements 
of  the  muscles.  It  usually  affects  the  muscles  of  the  extremities,  face,  and 
tongue.    As  a  rule,  these  movements  are  not  present  when  the  child  sleeps. 

Etiology. — As  a  rule,  this  disease  is  most  prevalent  between  the  ages 
of  7  and  14  years.  Chorea  generally  occurs  in  bright,  precocious  children. 
It  is  seen  more  than  twice  as  frequent  in  girls  as  in  boys,  and  the  dispro- 
portion becomes  even  greater  after  puberty.  It  is  extremely  rare  in  dark- 
skinned  races.  Chorea  rarely  becomes  chronic,  although  it  recurs  in  about 
one-third  of  the  cases.  It  is  more  likely  to  recur  in  girls.  Fright  and  shock 
are  frequently  the  causes  of  this  disease. 

Steven  Mackenzie^  reports  439  cases.  The  largest  number  of  attacks 
occurred  in  the  thirteenth  year. 

34  per  cent,  occurred  between  5-10  years 

43  per  cent,  occurred  between    10-15  years 

16  per  cent,  occurred  between   15-20  years 


*The  Care  of  Speech  Defectives,  Medical  Record,  Feb.  22,  1913. 
•British  Medical  Journal,  February,  1887. 


CHOREA.  745 

Sachs  reported  a  case  seen  in  a  child  under  1  year  of  age,  and  several 
cases  seen  in  children  between  2  and  3  years  of  age.  The  reported  con- 
genital cases  are  usually  mistaken  instances  of  organic  cerebral  disease. 

Sinkler  found  that  of  328  cases  232  were  females  and  96  males. 
Gowers  studied  the  statistics  of  1000  cases  and  found  365  in  boys  and  635 
in  girls. 

Morris  J.  Lewis,  of  Philadelphia,  studied  717  cases  and  found  that 
the  largest  number  occurred  in  March,  the  next  largest  number  in  May, 
and  that  the  curve  corresponds  with  the  rheumatism  curve. 

My  own  experience  is  that  we  have  an  equal  number  of  cases  occurring 
in  the  spring  and  fall,  depending  on  the  amount  of  study  and  the  sedeniary 
life  induced  hy  too  much  school. 

In  a  large  children's  service  among  the  poor  tenement  population,  out 
of  100  cases  of  chorea  examined  by  me,  80  cases  occurred  in  females;  20 
cases  in  males. 

All  of  my  cases  were  school  children  who  were  apparently  well  when 
their  chorea  commenced. 

Overstudy  in  School. — Sturges,  in  London,  has  given  considerable  at- 
tention to  the  question  of  overstudy,  and  he  believes  that  it  is  an  impor- 
tant etiological  factor  in  the  causation  of  this  condition.  Overstudy  (ap- 
parent) may  mean  only  inability  to  study  due  to,  lack  of  mental  concen- 
tration. 

Chorea  frequently  follows  the  infectious  diseases.  It  is  seen  after 
scarlet  and  typhoid  fever.  I  have  seen  chorea  of  a  very  severe  type  follow 
a  fright  and  also  after  bad  dreams,  in  school  girls.  Eeflex  causes,  such  as 
phimosis,  pin  worms,  and  delayed  menstruation,  are  cited  by  some  authors. 

Reflex  Causes  Due  to  the  Eye. — I  have  usually  sent  children  suffering 
with  chorea  to  the  eye  specialist  to  see  if  improvement  could  not  be  ob- 
tained by  using  eye-glasses.  I  believe  that  headaches  due  to  astigmatism 
can  be  relieved,  so  also  can  astigmatism  be  modified  when  suitable  glasses 
are  prescribed.  I  do  not  believe  that  the  chorea  per  se  was  cured  in  a 
single  case.  I  do  not  refer  to  those  cases  of  habit  spasm  so  frequently  seen 
in  nervous  children,  but  I  refer  to  distinct  chorea. 

Vaginal  discharges  will  frequently  excoriate  the  vulva.  This  produces 
itching,  and  the  scratching  therefrom  frequently  induces  masturbation. 
This  is  a  frequent  forerunner  of  chorea. 

Eeflex  conditions,  such  as  adenoids  and  polypoids,  have  been  reported 
from  time  to  time. 

The  reflex  causes  are  overestimated.  Adepoids  are  more  likely  to  in- 
duce tics  rather  than  chorea. 

Neurotic  make-up  plays  a  distinct  predisposing  r61e  (neuroses  or  psy- 
choses in  family) , 


746  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Table  No.  75. — The  Association  of  Chorea  with  Rheumatism. 

Steiner  reports 252  eases  4  suffered  with  rheumatism 

Sachs  reports 70  eases  8  suffered  with  rheumatism. 

Sinkler  reports 279  cases  37  suffered  with  rheum.atism 

Crandall  and  Holt  report..    146  cases  63  suft"ered  with  rheumatism. 

Fischer  reports 100  cases  25  suffered  with  rheumatism 

Twenty-five  Per  Cent,  of  my  Cases  had  Undoubted  Rheumatism. — 
By  rheumatism  I  include  cases  that  complained  of  pains  in  or  around  the 
joints.    At  times  they  were  described  as  "growing  pains"  by  the  parent. 

Frequency  of  Endocarditis. — Valvular  lesions  have  been  seen  by  me 
in  chorea  without  any  antecedent  joint  lesions.  The  ease  with  which  rheu- 
matism is  overlooked  in  children  makes  the  clinical  history  as  given  by 
parents  doubtful.  It  is,  therefore,  possible  that  there  are  many  more  cases 
of  rheumatism  associated  with  chorea  than  are  reported. 

Association  with  Tonsillitis. — Of  the  100  cases  of  chorea  previously 
reported  by  me,  more  than  80  cases  had  enlarged  tonsils.  It  seems  quite 
probable  that  the  tonsil  is  the  point  of  entrance  of  the  pathogenic  bacteria 
which  cause  chorea,  and  most  probably  rheumatism  and  endocarditis. 

Pathology. — There  are  no  distinct  pathological  lesions  which  can  be 
attributed  to  chorea.  Sachs  says  that  the  pathology  of  chorea  is  still  a 
great  mystery.  Not  that  autopsies  are  wanting,  but  there  have  been  so  many 
different  post-mortem  findings  described  that  each  writer  may  be  said  to 
have  his  own  views. concerning  the  pathology  of  chorea. 

Symptoms. — Chorea  usually  begins  with  prodromal  symptoms.  The 
children  as  a  rule  are  very  irritable,  depressed,  and  cannot  hold  their  arms 
or  legs  quiet.  They  complain  of  pain  in  various  parts  of  the  body.  The 
main  symptoms  which  attract  the  attention  of  parents  or  nurses  are  motor 
disturbances.  These  consist  of  involuntary  twitchings  affecting  various 
muscles  or  groups  of  muscles.  The  muscles  of  the  hands,  the  legs,  the  facial 
muscles,  and  the  tongue  show  this  choreic  twitching.  At  times  there  is  a 
decided  interference  with  speech.  A  point  worth  noting  is  that  the  child 
cannot  control  these  movements  voluntarily.  The  greater  the  effort  to  con- 
trol these  movements,  the  more  the  twitching  will  be  noticed.  Sachs  em- 
phasized the  fact  that  in  doubtful  eases  choreic  movements  of  the  tongue 
will  often  prove  the  nature  of  the  disease.  This  I  have  frequently  been  able 
to  verify  when  it  was  a  question  of  habit  spasm  or  true  chorea.  There  is  a 
certain  awkwardness  which  is  typical  in  a  choreic  patient.  This  can  be 
noticed  when  the  child  attempts  to  do  anything.  Choreic  movements  do 
not  occur  as  a  rule  in  the  night  when  the  child  sleeps.  The  pupils  are  fre- 
quently dilated.  Children  are  sometimes  punished  at  school  for  restlessness 
which  is  the  beginning  of  true  chorea,  and  it  is  only  later  in  the  disease  that 
the  true  character  of  the  same  is  detected.  In  some  cases  but  one-half  of 
the  body  (hemi-chorea)  is  affected.    In  other  cases  choreic  movements  are 


CHOREA.  747 

stronger  in  the  upper  than  in  the  lower  extremities.  Children  seem  to 
suffer  muscidar  weakness  and  there  is  loss  of  muscular  power.  A  peculiarity 
of  chorea  is  that  in  spite  of  the  constant  muscular  twitching  there  is  little 
exhaustion.    The  reflexes  show  no  abnormality. 

Condition  of  the  Heart. — Very  frequently  a  systolic  murmur  has  been 
heard  during  the  course  of  chorea.  This  systolic  murmur  persists  for  months 
after  the  last  symptoms  of  chorea  disappear.  Pains  in  the,  large  joints  are 
frequently  described.  I  have  invariably  noted  a  slight  rise  in  the  tem- 
perature (101°  F.)  when  the  joint  pains  or  endocarditis  existed.  When 
chorea  appeared  without  evidences  of  cardiac  or  arthritic  complications  the 
temperature  invariably  remains  normal. 

Fannie  S.,  11  years  old,  was  a  very  anaemic  girl.  She  had  been  sick  for  two 
months  with  tonsillitis  and  influenza.  She  was  compelled  to  stay  away  from  school, 
and  in  order  to  catch  up  with  her  class,  studied  very  hard,  especially  at  night,  until 
she  passed,  her  examinations. 

History  Given  by  Mother. — The  child  complained  of  headache,  her  appetite  was 
poor,  the  bowels  constipated.  She  was  restless  by  day  and  did  not  sleep  well  at 
night.  She  had  nervous  twitchings  of  the  arms  and  legs.  The  fingers  were  never 
still.  She  did  not  appear  contented  at  anything.  Her  eyes  were  examined  by  an  ocu- 
list, who  prescribed  eyeglasses.  He  said  the  child  had  eye  strain.  The  mother 
believed  there  was  a  slight  benefit  after  wearing  the  glasses. 

When  the  child  was  brought  to  me,  there  were  distinct  evidences  of  chorea,  with 
twitchings  of  the  face,  the  tongue,  the  hands  and  the  legs.  Four  drops  of  Fowler's 
solution  was  prescribed,  three  times  a  day,  and  gradually  increased  until  7  drops  were 
given  three  times  a  day.  All  school  and  study  was  stopped.  Cold  sponging  and  a 
cold  shower  was  ordered  every  morning  and  evening.  Cereals,  vegetables,  milk,  and 
fruit  were  given.  All  meat  was  stopped.  An  active  outdoor  life  and  all  quiet  games 
and  sports  were  recommended.  Under  this  treatment  the  symptoms  gradually  sub- 
sided and  the  child  recovered.  One  year  later  the  same  symptoms  returned,  and  it 
was  found  that  the  cause  of  the  relapse  was  overstudy.  I  prescribed  "remove  the 
cause,"  namely,  take  the  girl  away  from  school. 

Course. — The  usual  course  of  this  disease  is  from  six  to  ten  weeks, 
although  it  may  extend  to  four  months.  I  have  seen  cases  in  which  there 
was  a  severe  attack  in  the  spring,  which  seemed  to  disappear  entirely  dur- 
ing the  summer,  and  suddenly  reappear  with  greater  intensity  in  the  fall. 

Prognosis. — The  outcome  of  a  case  of  chorea  is  usually  good,  especially 
so  if  we  are  dealing  with  intelligent  mothers  and  nurses.  The  prognosis  is 
bad  if  endocarditis  or  other  organic  lesions  are  associated. 

Treatment. — Best  Treatment. — It  is  useless  to  attempt  to  modify  se- 
vere or  mild  chorea  without  enjoining  absolute  rest  in  bed.  The  eyes  should 
be  protected  from  a  strong  light;  or  the  room  should  be  darkened  by  drawing 
the  shades.  In  some  cases  I  have  kept  children  in  bed  for  one  week  before 
the  twitchings  ceased.  In  severer  cases  it  may  be  necessary  to  keep  a  child 
in  bed  at  least  two  or  more  weeks.  The  southing  iiifuence  of  this  absolute 
rest  in  bed  will  do  more  good  than  all  the  drugs  combined, 


748  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Hygienic  Treatment. — A  child  should  be  removed  from  school  and 
thus  guarded  against  all  psychical  disturbances.  Cold  sponging  of  the  en- 
tire body  and  cold  spinal  douches  have  been  found  very  beneficial. 

The  diet  should  be  light  and  very  nutritious.  All  cereals  should  be 
given  (see  diet  list  for  a  child  from  3  to  10  years  old,  page  154).  Meat 
should  be  avoided,  although  meat  soups  and  white  meat  or  chicken  may  be 
permitted.  Later  fresh  air  and  quiet  out-of-door  exercise,  games,  and  sports 
are  necessary  adjuncts  in  the  treatment  of  this  disease. 

Medicinal  Treatment. — Iron  and  arsenic  should  always  be  remem- 
bered in  the  treatment  of  this  disease.  We  can  begin  with  4  or  5  drops  of 
Fowler's  solution,  three  times  a  day,  and  watch  the  systemic  effect,  with 
gradually  increasing  doses  until  10  drops,  three  times  a  day,  are  given. 
Great  care  should  be  used  to  avoid  arsenical  poisoning  when  large  doses  of 
Fowler's  solution  are  given.  In  some  children  a  peculiar  idiosyncrasy 
exists  which  renders  them  liable  to  systemic  poisoning.  Semple  has  re- 
ported multiple  neuritis  following  the  use  of  arsenic  in  the  treatment  of 
chorea.  I  have  seen  multiple  neuritis  in  a  rachitic  child  having  chorea 
minor.  The  child  received  4  drops  of  Fowler's  solution  for  six  weeks. 
When  the  arsenic  was  withdrawn,  the  neuritis  subsided.  Of  the  prepara- 
tions of  iron  on  the  market,  neoferrum  in  doses  of  1  or  2  teaspoonfuls  has 
served  me  very  well.  Another  preparation  which  I  have  frequently  used  is 
the  liquor  ferri  peptomangan  (Gude)  in  doses  of  a  teaspoonful,  three  times 
a  day,  after  meals.  Ferratin,  5  to  10-grain  doses,  three  times  a  day,  after 
meals,  is  also  beneficial.  Antipyrin  and  bromide  of  sodium  may  also  be 
used  in  some  cases.  When  chorea  is  associated  with  rheumatism,  the  salicy- 
late of  soda  in  3  to  5-grain  doses,  or  salipj^rin  in  the  same  quantity,  may 
be  given  three  or  four  times  a  day.  Some  authors  advise  against  the  use 
of  chloral  hydrate;  my  personal  experience  with  3-grain  doses  of  chloral 
hydrate  given  morning  and  evening  has  been  very  good.  If  choreic  twitch- 
ing does  not  improve  after  several  weeks  of  persistent  treatment,  then  a 
cold  pack  may  be  tried.  A  sheet  wrung  out  in  cold  water  at  a  temperature 
of  60°  F.  should  be  wrapped  around  the  child  for  one  hour  every  morning 
and  evening.  Not  only  have  I  seen  a  soothing  effect  on  the  nervous  system 
from  these  packs,  but  they  frequently  promote  sleep.  That  electricity  is  of 
value  in  this  condition  is  doubted  by  many.  I  have  seen  one  or  two  cases  in 
which  excellent  results  were  obtained  from  the  use  of  a  weak  galvanic  cur- 
rent over  the  spinal  nerves.  On  the  other  hand  I  have  frequently  seen  no 
effect  whatsoever  from  the  treatment  with  mild  or  strong  galvanic  currents. 

Sachs  recommends  hyoscyamin  in  tablet  form,  Vjoo  grain,  when  rest- 
lessness and  insomnia  exist.  Hyoscyamin  should  only  be  administered  in 
the  afternoon  and  evening.  Massage  is  sometimes  of  value  in  conjunction 
with  electricity;   it  has  a  soothing  effect  on  the  nervous  system  and  stimu- 


HYSTERIA.  749 

lates  nutrition.     It  is  especially  valuable  at  night  and  I  have  seen  a  j^ro- 
found  sleep  follow  thorough  massage  of  the  body. 

Hysteria. 

It  is  an  important  matter  to  recognize  this  condition  when  met  with 
in  children.  It  is  rarely  seen  in  children  under  7  years  of  age,  although 
cases  are  on  record  of  distinct  hysteria  having  been  met  with  in  infancy. 
In  my  experience  children  rarely  simulate  disease.  I  have  seen  children 
imitate  an  invalid  mother  and  complain  of  imaginary  pains  and  aches  at 
the  same  time  and  in  the  same  portions  of  the  body  as  the  mother.  Very 
neurotic  children,  susceptible  children,  and  children  having  bad  habits,  such 
as  masturbation,  are  more  prone  to  develop  hysteria.  Charcot  maintained 
that  hysterical  persons  are  hysterical  because  they  are  mentally  degenerate. 

Pathology. — Hysteria  is  not  a  fatal  disease,  hence  we  have  no  specific 
pathological  lesions.  The  theory  concerning  the  mobility  of  the  neuron, 
while  very  interesting  and  scientific,  does  not  explain  the  hysterical  par- 
oxysms. Hysteria  is  not  a  psychosis  as  is  generally  supposed.  There  are  no 
known  demonstrable  lesions.  While  in  some  cases  the  whole  brain  seems 
disturbed  and  involved,  in  other  cases  but  one-half  of  the  brain  is  involved. 

Symptoms  and  Diagnosis. — Paralyses  occur  in  hysteria  which  simulate 
those  due  to  central  nervous  disease.  As  a  rule,  however,  they  disappear. 
The  hysterical  paroxysm  usually  follows  close  upon  an  aura.  It  "sometimes 
comes  on  suddenly,  although  it  may  be  preceded  by  a  spell  of  laughing  or 
crying.  Children  old  enough  to  complain  describe  a  "lump  in  the  throat" 
similar  to  the  "globus  hystericus"  which  occurs  in  the  adult. 

►Some  symptoms  closely  resemble  epilepsy.  Headache  is  complained 
of  at  times.  The  scrisaming  and  shouting  gradually  cease  as  the  attack 
subsides.  The  following  description  given  by  Taylor  and  Wells  describes 
the  attack  so  closely  that  I  repeat  it:  "The  patient  sinks  down  or  falls 
prone  upon  the  back,  with  the  limbs  extended  and  rigid,  but  with  the  fingers 
and  toes  flexed;  the  eyes  are  usually  rolled  slowly  from  right  to  left,  or 
crossed;  the  jaws  are  firmly  closed;  the  breathing  becomes  slow  and 
labored,  and  later  hurried,  the  face  flushed  or  bluish,  the  neck  turgid;  the 
cardiac  action  becomes  more  rapid  and  forcible,  and  consciousness  is 
almost,  but  never  entirely,  lost.  Sensation  is  much  obtunded,  and  abolished 
in  some  portions  of  the  body.  Soon  clonic  movements  succeed — a  tremor 
affecting  the  muscles  of  the  trunk,  extremities,  and  face.  This  alternates 
with  electric-like  startings,  during  which  the  patient  may  fling  himself 
furiously  about,  or  actually  out  of  bed.  Presently  this  stage  ends  with 
sighs,  and  is  followed  by  a  short  sleep."  Some  authors  describe  a  series 
of  dramatic  movements.  There  may  be  opisthotonos.  The  child  may  have 
a  bowing  of  the  lumbar  curve  so  that  it  rests  upon  its  head  and  heek 


^50  DISEASES    OF    THE    XER VOL'S    SYSTEM. 

There  may  be  a  series  of  attacks  recurring  so  that  as  many  as  two  hundred 
paroxysms  have  been  recorded  by  Sachs.  I  have  seen  a  severe  form  of 
hysteria  with  over  ten  paroxysms  during  one  hour.  Some  tender  areas 
frequently  noted  in  children,  over  the  ovaries  and  spine  in  girls,  and  the 
testicles  of  boys,  are  very  sensitive.  Some  authors  claim  that  pressure  over 
these  areas  will  sometimes  invite  an  attack  of  hysteria;  on  the  other  hand 
pressure  over  these  same  sensitive  areas  will  sometimes  stop  an  attack. 

Tomiting  when  it  does  occur  is  a  very  serious  symptom.  We  do  not 
have  the  same  forms  of  tremor  as  are  seen  in  adults. 

Borborigmus  (rumbling  gas  in  the  intestines)  is  occasionally  heard  in 
this  condition. 

Epidemics  of  hysteria  are  frequently  described.  J.  ]\Iadison  Taylor 
describes  one  occurring  in  a  church  home  at  Philadelphia.  I  have  fre- 
quently seen  children  in  one  locality  suffer  with  various  manifestations  of 
hysteria,  in  which  we  could  easily  trace  the  origin  to  one  particular  child. 

Prognosis  and  Course. — The  duration  of  the  disease  depends  on  the 
surroundings  of  the  child,  ilild  hysteria  will  sometimes  disappear  after  a 
change  of  scene  and  air  of  several  weeks.  In  some  instances  a  case  may 
last  years  or  through  the  child's  whole  life. 

It  is  always  well  to  remember  that  hysteria  is  difEicult  to  cure.  If  a 
child  is  sensitive  and  subjected  to  impressions  from  a  neurotic  family,  then 
a  cure  will  be  difficult.  The  outcome  of  any  ease  of  hysteria  depends  on 
the  character  of  the  surroundings  and  on  the  mental  influences  with  which 
the  child  is  brought  in  contact,  rather  than  on  drug  treatment. 

Case  I. — A  girl  9  years  old  was  brought  to  me  for  the  relief  of  headache.  She 
complained  of  a  continual  headache  night  and  day.  The  appetite  was  poor,  the 
bowels  moved  sluggishly.  She  was  restless  during  the  d&y,  and  had  insomnia  at  night. 
She  complained  of  bad  dreams.  She  looked  haggard  and  worn,  as  though  she 
were  convalescing  from  some  severe  illness.  She  was  anaemic  and  had  cold  extremi- 
ties. Heart,  lungs,  liver,  and  spleen  were  normal.  She  was  a  very  restless  child  with 
marked  hyperaesthesia.      The  patellar  reflexes  were  exaggerated. 

Subjective  Symptoms. — The  child  complained  of  pain  in  every  part  of  her  body. 
On  being  asked,  "Does  your  side  hurt?"'  she  answered,  '"Yes,  my  pains  are  in  the  side 
and  in  the  back,  just  like  my  mother's."  I  referred  the  child  to  an  oculist  for  an 
opinion  as  to  the  eyes,  and  his  answer  was:  nothing  abnormal,  no  astigmatism.  The 
child  cried  on  the  slightest  provocation,  and  was  also  almost  convulsed  with  laughter 
for  trivial  matters.  The  diagnosis  was  hysteria.  The  child  had  a  headache,  or  a 
backache,  and  always  complained  of  some  ache.  It  was  quite  evident  that  the  child's 
hysteria  was  due  to  suggestif/n  by  the  mother,  icho  was  an  invalid. 

The  treatment  consisted  in  removing  the  child  to  an  aunt  in  a  neighboring  city. 
amid  healthy  surroundings.  Iron  was  ordered  to  build  up  the  system,  and  bromide 
of  soda  in  lO-grain  doses  was  given  every  night  for  one  week,  later  every  other  night. 
Electricity,  the  baths,  and  massage  were  used  vdih  great  success.  In  three  months 
the  child  had  rosy  cheeks,  slept  well,  was  cheerful,  and  did  not  complain  of  any  pain. 
It  was  strange,  however,  that  when  taken  back  to  her  mother,  she  immediately  re- 


MULTIPLE    NEUKITIS.  751 

lapsed  into  hor  former  habit  of  complaining.  We  determined  to  remove  her  per- 
manently, and  she  remained  well  for  over  a  year  when  I  last  heard  of  her. 

Case  11.' — General  Hysteria  and  Nervous  Vomiting. — A  girl  12  years  old  was 
brought  to  my  children's  clinic  for  the  relief  of  vomiting.  She  was  very  nervous 
and  complained  of  pains  all  over  her  body.  She  complained  also  of  pains  in  her 
stomach  before  and  after  eating.  Her  mental  condition  was  poor,  the  hands  and 
feet  were  cold.  She  complained  of  epigastric  pains  for  the  last  six  years.  From 
the  mother  I  learned  that  the  child  was  frightened  by  a  dog  and  since  that  time  she 
has  been  very  sensitive  to  the  slightest  impression.  The  gastric  contents  were 
syphoned  off  after  a  test  meal  and  a  hyperchlorhydria  was  found.  The  urine  con- 
tained acetone. 

The  treatment  of  this  case  was  most  successful  when  large  doses  of  bromides 
were  given. 

Treatment. — Study  the  cause  or  causes,  and  remove  them  if  possible. 
Change  the  surroundings  of  the  child  by  removing  to  a  cheerful  but  quiet 
home.  If  the  case  occurs  in  the  country,  bring  the  child  to  the  city.  In 
any  event  the  main  point  should  be  to  change  the  entire  scene  and  sur- 
roundings. If  a  child  is  in  an  institution,  remove  it  from  the  same  if  it 
is  at  all  possible.  The  person  in  charge  of  the  child  should  be  either  a 
very  intelligent  mother  having  a  positive  influence  over  the  child,  or  a 
mild-mannered  trained  nurse.  All  orders  of  the  physician  should  be 
strictly  obeyed  without  having  the  child  feel  that  vigorous  treatment  is 
being  used.  This  psychosis  requires  educational  treatment  as  has  just  been 
described. 

Hygienic  Treatment. — If  the  child  is  old  enough,  a  walk  should  be 
ordered  several  times  a  day.  The  bicycle  and  horseback  are  valuable  ad- 
juncts. The  sponge  bath  or  the  tub-bath  aided  by  a  cold  shower  or  spray 
chiefly  over  the  spine,  head,  and  neck,  have  very  tonic  properties. 

Hydrotherapy  properly  used  is  one  of  the  most  valuable  aids  in  pro- 
moting a  cure. 

Nothwithstanding  the  shock  of  a  cold  spray,  the  same  should  be  ordered 
winter  or  summer. 

After  the  bath  the  body  should  be  rubbed  vigorously,  or  better  yet, 
massage  should  be  given.  I  have  always  found  a  very  soothing  effect  on 
the  nervous  system  by  giving  gentle  but  thorough  massage.  Another  reme- 
dial agent  which  must  be  used  regularly  is  electricity.  This  should  be  used 
daily  by  means  of  a  mild  faradic  current,  one  electrode  to  be  applied  over 
the  spine,  the  other  over  the  phrenic  nerve.  If  no  benefit  is  noticed  after 
this  treatment  is  tried,  then  static  electricity  can  be  used. 

Multiple  Neuritis  (Polyneuritis). 
This  is  frequently  termed  a  peripheral  neuritis,  as  it  is  an  affection 
of  the  terminal  branches  of  the  nerves.     It  usually  affects  all  the  nerves 


*This   case   was   presented   by   me   to   the   Section   on   Pediatrics,   Academy  of 
Medicine,  February  14,  190  L 


753  DISEASES    OF    THE    NERVOUS    SYSTEM. 

of  the  limbs  on  both  sides  of  the  body.  Starr  gives  the  following  classifica- 
tion : — 

"1.  Toxic  cases  due  to  the  action  of  a  poison  derived  from  without 
the  body.  These  poisons  are  alcohol,  carbonic  oxide  gas,  bisulphide  of  car- 
bon, the  coal-tar  products,  especially  sulphonal  and  trional;  and  nitro- 
benzol;    also,  arsenic,  lead,  mercury,  copper,  phosphorus,  and  silver. 

"2.  Infectious  cases  due  to  some  agent  acquired  or  developed  within 
the  body,  as  an  •  accompaniment  or  sequel  of  diphtheria,  grippe,  typhoid, 
typhus,  malaria,  scarlet  fever,  measles,  whooping-cough,  smallpox,  erysipe- 
las, and  septicgemic  conditions,  including  gonorrhoea  and  puerperal  fever, 
epidemic  forms  of  beriberi  or  kakke,  and  leprous  neuritis, 

"^'3.  Cases  due  to  general  diseased  states  of  the  body  whose  origin  is 
undetermined,  such  as  rheumatism,  gout,  diabetes,  anemia,  marasmus,  gen- 
eral malnutrition  consequent  upon  tuberculosis,  syphilis  and  senility,  car- 
cinoma, and  local  malnutrition  produced  by  arterial  sclerosis. 

"4.  Cases  due  to  exposure  to  cold  and  developing  spontaneously  with- 
out known  cause." 

The  most  common  type  of  multiple  neuritis  met  with  in  children  is 
either  the  diphtheritic  type  or  that  resulting  from  poisons  in  the  blood, 
such  as  the  prolonged  administration  of  Fowler^s  solution  (arsenical  poi- 
soning) . 

Symptoms  and  Diagnosis. — Multiple  neuritis  may  come  on  suddenly 
or  the  onset  may  be  gradual.  The  special  senses  are  rarely  involved  in 
this  condition.  The  motor  symptoms  are  as  marked  as  the  sensory.  Paral- 
ysis comes  on  first  as  a  muscle  weakness,  and  gradually  increases  until  dis- 
tinct paralysis  is  present.  The  extensor  muscles  of  the  wrist,  hands,  and 
feet  give  the  wrist-drop  and  the  foot-drop.  Very  rarely  the  muscles  of  all 
four  extremities  in  addition  to  the  muscles  of  the  trunk  and  neck  are  in- 
volved. The  knee-jerk  usually  disappears  early  when  neuritis  follows  diph- 
theria. The  paralyzed  muscles  are  relaxed,  flabby,  and  atrophied.  An 
important  symptom  is  that  faradic  excitability  is  absent  and  that  the  mus- 
cles respond  to  a  galvanic  current  only.  This  symptom  is  identical  with 
that  found  in  acute  anterior  poliomyelitis.  The  reaction  of  degeneration  is 
present. 

There  is  usually  no  incontinence  of  bladder  and  bowel.  Atrophy  is 
another  prominent  symptom.  The  condition  is  similar  to  that  seen  in 
poliomyelitis.  There  may  be  other  vasomotor  disturbances  such  as  uni- 
lateral flushing  of  the  skin,  or  small  areas  may  show  a  high  glossy  flush. 
This  last  symptom  was  very  prominent  in  one  of  my  cases.  An  oedema 
of  the  affected  parts  is  described  by  some  authors.  As  a  rule  the  areas 
affected  are  very  sensitive,  so  that  we  have  distinct  hyperaesthesia.  In  other 
cases  the  opposite  condition  prevails  and  there  are  areas  of  local  anaesthe- 
sia.   The  disease  may  be  ushered  in  by  a  fever.    The  temperature  may  rise 


PAYOR    iNOCTURKUS.  753 

to  103°  or  104°  F.,  and  remain  several  days.  The  pulse-rate  is  correspond- 
ingly increased  and  may  reach  140  or  IGO. 

Gastric  disturbances  associated  with  diarrhoea  may  be  present.  The 
spleen  is  frequently  enlarged,  and  an  examination  of  the  blood  will  show 
a  distinct  leucocytosis,  the  latter  condition  when  neuritis  is  a  sequela  to 
an  infectious  disease. 

Course  and  Prognosis. — As  a  rule,  multiple  neuritis  lasts  from  several 
weeks  to  several  months,  and  then  ends  in  recovery.  The  cases  seen  by  me 
associated  with  chorea  in  which  arsenical  poisoning  took  place,  invariably 
unproved  when  the  drug  was  withheld  for  a  short  time.  Rarely  does  the 
paralysis  remain  permanent.  The  prognosis  can  best  be  gauged  by  noting 
the  electrical  reactions.  If  the  reaction  of  degeneration  is  present  after 
the  disease  has  lasted  several  months,  then  a  permanent  lesion  must  be 
suspected.  If,  on  the  other  hand,  there  is  only  a  slight  difference  in  the 
reaction  following  the  use  of  the  faradic  current,  then  a  complete  recovery 
may  be  expected.  Some  cases,  although  severely  atrophied,  will  ultimately 
recover.     If  myelitis  complicates  this  condition,  the  prognosis  is  serious. 

Treatment. — The  system  should  be  strengthened  with  proper  nutrition. 
The  patient  should  be  made  as  comfortable  as  possible.  If  severe  pains 
exist,  then  large  doses  of  bromide  should  be  given,  with  or  without  codeine, 
until  all  pain  is  relieved.  In  some  cases  the  local  application  of  warmth 
over  the  affected  limb  is  very  soothing.  I  frequently  use  a  warm  Imth  at 
night,  which  is  very  soothing  and  promotes  sleep. 

Gentle  friction  and  massage  are  beneficial.  Eestoratives,  such  as  cod- 
liver-oil,  maltine  with  hypophosphites,  and  iron  should  be  used.  The 
syrup  of  the  iodide  of  iron  is  a  good  restorative.  Butter,  cream,  and 
cereals  are  excellent  tonics.  Strychnine  and  nux  vomica  are  valuable  if 
the  appetite  is  poor;  otherwise  they  have  no  specific  value. 

Pavok  Noctuenus  (Night  Terrors). 

Children  apparently  healthy  will  sometimes  awaken  from  a  sound 
sleep  and  shriek  or  scream. 

Etiology. — In  this  condition  children  usually  show  some  disturbance 
of  the  stomach  or  bowels  which  may  have  been  the  exciting  cause  of  the 
night  terror.  Eeflex  irritability  is  frequently  caused  by  intestinal  worms, 
by  adenoid  vegetation,  or  in  the  male  child  by  an  elongated  -prepuce,  or 
by  phimosis.  Such  children  usually  possess  a  neuropathic  constitution  by 
inheritance.  Henoch  states  that  some  children  may  have  hallucinations 
during  the  day.  These  attacks  occur  but  once  during  the  night,  and  after 
reassuring  the  child  that  there  is  no  danger,  it  will  again  fall  asleep. 

Symptoms. — Some  children  awaken  frightened  and  screaming,  while 
others  will  grasp  anything  within  reach  in  a  bewildered  manner.     They 

48 


754  DISEASES    OF    THE    NERVOUS    SYSTEM. 

frequently  imagine  that  animals  are  in  the  room.  The  effect  of  too  rigid 
discipline  will  sometimes  show  itself  by  bad  dreams  at  night,  and  in  a 
distinct  hysterical  symptom,  such  as  fright  and  terror. 

Course  and  Prognosis. — If  these  night  terrors  are  associated  with  mild 
nervous  attacks  during  the  day,  or  if  they  partake  of  the  nature  of  epileptic 
attacks,  then  a  cautious  prognosis  should  be  given.  The  inclination  to 
serious  brain  or  nervous  trouble  must  always  be  remembered;  therefore, 
no  opinion  should  be  ventured  until  a  case  has  been  properly  observed. 

Treatment. — Children  having  night  terrors  should  be  removed  from 
school  to  insure  perfect  tranquillity.  There  should  be  a  distinct  change  of 
scene,  a  change  from  the  city  to  the  country,  or  vice  versa,  will"  be  bene- 
ficial. Any  reflex  cause,  if  present,  should  be  attended  to,  and,  if  possible, 
removed.  Fresh  air,  out-of-door  life,  and  restoratives  are  indicated.  Such 
children  appear  less  frightened  if  they  sleep  in  the  room  with  an  adult, 
and  are  thus  reassured  that  there  is  no  danger  present. 

Cold  or  gradually  cooled  bathing  or  a  spray  over  the  spine  will  tone 
the  nervous  system.  It  should  be  used  in  a  warm  room  daily.  Five  grains 
of  sodium  bromide  may  be  given  before  retiring. 

Masturbation  ( 0  nanism  ) . 

This  habit  is  very  frequently  seen  in  children.  I  have  seen  it  in  girls 
as  well  as  in  boys. 

Causes. — Any  irritation  of  the  genital  tract  that  will  cause  itching 
may  be  the  origin  of  masturbation.  In  boys  an  elongated  prepuce,  or 
friction  from  phimosis,  may  give  rise  to  this  condition.  Very  acid  urine 
may  cause  excoriation  and  thus  invite  this  bad  habit.  Excoriations  at  or 
near  the  external  meatus  may  be  the  starting  point.  We  see  this  condition 
quite  frequently  in  girls  when  preputial  adhesions  due  to  smegma  or  dirt 
cause  an  irritation  of  the  clitoris  or  when  pin  worms  wander  from  the  anus 
to  the  vagina;  thus  worms  frequently  set  up  an  irritation  resulting  in  mas- 
turbation. A  diaper  if  too  tightly  pinned  can  set  up  an  irritation,  especially 
in  female  children. 

Symptoms. — Children  usually  place  their  hands  on  the  genitals  and 
masturbate.  They  sometimes  rub  their  thighs  together  until  exhausted. 
During  this  friction  their  face  will  be  flushed  and  they  appear  irritable. 

Such  children  suffer  with  profound  ansemia  as  the  result  of  this  habit; 
and  from  loss  of  sleep.  Older  children,  especially  boys,  will  masturbate 
chiefly  at  bedtime.     They  are  peevish,  irritable,  and  very  sensitive. 

An  infant  about  nine  months  old  was  seen  by  me  in  consultation  with  Dr.  L. 
P.  Harris,  of  New  York  City.  The  mother  complained  that  the  child  continually 
rubbed  its  thighs.  The  face  was  flushed  during  the  rubbing;  later  the  child  would 
fall  asleep  as  though  from  exhaustion.     This  condition  seemed  to  occur  chiefly  when 


Masturbation.  755 

the  child  was  placed  on  the  bed  or  held  on  the  lap.     An  examination  of  the  genitals 
showed  that  they  were  very  red  and  excoriated  from  the  constant  irritation. 

The  progfnosis  is  usually  good  if  the  habit  is  detected  early  and  the 
cause  removed  if  one  exists.  On  the  other  hand,  some  eases  will  persist 
in  spite  of  careful  treatment,  and  nothing  but  heroic  measures  will  effect 
a  cure,  as  the  following  case  will  illustrate : — 

An  infant,  female,  was  brought  to  me  for  the  relief  of  this  condition.  The 
child  had  masturbated  continually  for  several  months  and  was  so  emaciated  that 
the  parents  were  alarmed.  The  condition  was  so  bad  that  the  child  masturbated 
whenever  the  thighs  were  put  together.  A  pad  was  improvised  to  separate  the  thigh-j 
and  local  applications  of  lead  water  on  cotton  were  placed  over  the  genitals  to  reduce 
the  irritation.  Large  doses  of  bromides  were  administered  to  control  irritability  in 
the  ner\'ous  system.  The  child  was  kept  in  a  stupor  for  several  days  without  having 
the  condition  relieved.  The  symptoms  persisted  and  we  finally  were  compelled  to 
remove  the  child  to  the  St.  Marks  Hospital  where  Dr.  H.  J.  Garrigues  suggested  per- 
forming a  clitoridectomy.  This  case  was  published  in  extenso  in  Archives  of 
Pediatrics,  May,  1899.  The  child  made  a  perfect  recovery.  The  habit  did  not 
reappear. 

Treatment. — Eemove  the  cause  if  any  exists.  All  irritants,  such  as 
worms  or  eczema,  should  be  treated.  If  an  enlarged  prepuce  causes  this 
condition,  remove  it.  If  a  vaginal  discharge  exists,  treat  it  with  astrin- 
gents, and  thus  avoid  irritation.  If  worm's  are  present,  injections  of  quassia 
will  dislodge  them  (see  chapter  on  "Worms").  In  older  children  we  must 
remove  the  child  from  bad  company,  and  sometimes  it  will  be  necessary  to 
change  the  entire  surroundings  of  a  sensitive  but  well-meaning  child.  An 
ocean  voyage  is  beneficial.  The  system  should  be  strengthened  by  giving 
iron  and  strychnine.  Clean  habits,  a  rigid  hygiene,  and  a  daily  bath  are 
necessary.  Strict  supervision  by  night  as  well  as  by  day  with  the  aid  of 
a  trained  nurse  will  do  more  good  than  medicine.  Children  once  detected 
v.'ith  this  bad  habit  must  never  be  permitted  to  sleep  with  their  hands  under 
the  bedclothes. 

Circumcision  is  one  of  the  most  valuable  means  of  curing  this  habit. 
In  females,  especially  in  little  girls,  stripping  the  clitoris  and  cleansing  the 
smegma,  if  present,  will  frequently  modify  this  habit.  If  the  habit  persists 
in  spite  of  this  treatment,  then  a  radical  operation — clitoridectomy  (see 
clinical  case  given) — may  be  required. 


CHAPTER  III. 

SPASMOPHILIA. 

The  modem  conception  of  tetany,  true  laryngeal  spasm,  spastic  apncea 
and  convulsions  is  that  they  are  one  and  all  part  of  the  clinical  picture 
known  as  spasmophilia.  The  condition  is  characterized  by  an  irritability 
of  the  nervous  system.^ 

It  is  most  commonly  met  with  in  early  childhood,  and  distinguished 
by  galvanic  and  mechanical  hyperexcitability  of  the  peripheral  nerves ;  both 
tonic  and  clonic  convulsions  are  frequently  associated. 

Etiology. — There  is  a  diminution  in  the  quantity  of  calcium  salts  in 
the  brain,  and  a  corresponding  increase  in  calcium  phosphates  in  the  urine. 


Fig.  250. — Tetany.  Characteristic  attitude  of  the  hands  resembling  a 
rider  reining  in  his  horse.  Note  attitude  of  tlie  toes.  The  wrists  are 
rigid  and  flexed.  The  elbows  are  free.  The  fingers  are  flexed  at  the  meta- 
carpophalangeal joints.  In  this  case  facial  irritability  was  best  seen  by 
constant  spasm  in  the  orbicularis  palpebrarum.      (Original.) 

Musser  and  Goodman  found  a  high  percentage  of  ammonia  in  the  urine, 
rarely  below  5  per  cent.  This  output  of  ammonia  bears  a  distinct  relation 
to  tetany.  Berkley  and  Beebe  believe  that  the  parathyroids  are  concerned 
in  furnishing  enzymes  which  are  of  importance  in  the  intermediary  metab- 
olism of  nitrogen.  Jacobson  found  an  increase  of  ammonia  in  the  blood 
and  believes  that  such  ammonia  is  sufficient  to  cause  tetany  and  tremors. 
The  removal  of  the  parathyroids  alone  causes  tetany.  For  this  reason  the 
extract  of  the  thyroid  gland  has  been  advocated  for  the  relief  of  this 
condition. 

Von  Pirquet^  has  noted  specific  conditions:  that  in  the  normal  in- 
fant the   anodal   opening   contraction   does   not   occur   with   less   than   5 


'Sedgwick,  J.  P.:    St.  Paul  Medical  Journal,  Oct.,  1912. 

*Von   Pirquet:      "Galvanische  Untersuchungen  an  Sauglingen,"   Verhandl.    d. 
Gesellsch.  f.  Kinderh.,  Stuttgart,  1906.     Bergmann,  Wiesbaden,  1907. 

(756) 


SPASMOPHILIA.  757 

milliamperes.  In  spasmophilia  the  contraction  by  application  of  the  Stinzing 
normal  electrode  applied  over  the  median  or  peroneal  nerves  can  be  pro- 
duced with  less  than  5  milliiimperes  upon  the  anodal  opening.  The  reactions 
upon  anodal  closing  and  cathodal  closing  and  opening  are  also  frerjuently 
obtained  with  less  current  than  in  the  normal  child;  that  is,  with  less  than 
two  for  cathodal  closing,  three  for  anodal  closing,  and  five  for  cathodal 
opening. 

By  studying  these -reactions  we  have  been  able  to  learn  that  the  under- 
lying condition — namely,  spasmophilia — is  responsible  for  most  of  the  con- 
vulsions in  children,  true  laryngeal  spasm,  tetany,  and  spastic  apnoea. 
Thus,  we  may  state  that  if  an  anodal  or  cathodal  opening  contraction  with 
a  current  less  than  5  milliamperes  is  present,  it  shoius  that  spasmophilia, 
latent  or  active,  'is  present.  This  condition  is  most  common  after  the  fourth 
month  and  is  rarely  found  after  the  second  year. 

Symptoms  and  Diagnosis. — Gastro-intestinal  derangements  in  the  artifi- 
cially fed  infant  are  responsible  for  most,  if  not  all,  forms  of  spasmophilia. 
Active  symptoms  of  spasmophilia  frequently  disappear  when  an  improperly 
artificially  fed  infant  is  put  to  the  human  breast. 

If  we  tap  the  muscles  of  the  jaw,  a  slight  contraction  of  the  face 
ensues.  This  is  known  as  the  facial  phenomenon,  and  was  first  described 
by  Chvostek.    The  contractions  are  first  seen  in  the  orbicularis  palpebrarum. 

The  contraction  resembles  that  caused  by  the  sudden  passage  of  a 
galvanic  current.  It  is  sometimes  more  marked  on  one  side  of  the  face 
than  the  other,  and  in  some  cases  it  is  more  noticeable  in  the  upper — in 
others  in  the  lower — half  of  the  face.  A  similar  contraction  of  the  inner 
end  of  the  eyebrow  may  often  be  caused  b'y  tapping  on  the  temple.  The 
wrists  are  rigid  and  flexed.  The  elbows  are  free.  The  fingers  are  flexed 
at  their  metacarpophalangeal  joints.  There  may  be  a  constant  spasm, 
jerking  in  character,  continually  present. 

A  similar  phenomenon  is  known  as  Trosseau's  sign;  if  the  arm  is  com- 
pressed by  an  elastic  band  the  muscles  of  the  fingers  and  sometimes  of  the 
forearm  pass  into  the  tetanic  condition. 

Course. — The  course  of  this  disease  is  given  by  some  authors  as  from 
a  few  days  to  several  weeks.  In  one  case  observed  by  me  at  the  Willard 
Parker  Hospital  (see  Fig.  250),  the  tetanic  spasms  lasted  for  more  than  two 
months.  "Other  cases  seen  by  me  lasted  but  a  few  days  or  weeks  at  the 
longest. 

Prognosis. — ^The  prognosis  is  excellent  if  the  cause  of  the  tetany  is  a 
gastro-intestinal  disorder. 

There  are  instances  in  which  death  has  ensued  from  laryngeal  spasm 
or  from  general  convulsions.  When  a  very  frail  infant  has  severe  tetany 
of  the  upper  and  lower  extremities  with  retraction  of  the  head,  then  the 
prognosis  is  bad. 


758  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — The  deficiency  of  calcium  sajts  has  given  us  a  clue  to 
therapeutics,  showing  that  probable  imperfect  metabolism  of  certain  mineral 
salts  is  responsible  for  this  condition. 

The  thyroid  gland  has  been  successfully  employed  in  the  treatment 
of  tetany.  It  may  be  administered  raw  or  in  the  form  of  a  dried  gland  in 
doses  of  1  to  5  grains  per  day. 

Thorough  cleansing  of  the  gastro-intestinal  tract  is  demanded.  Por  a 
child  1  year  old,  a  3-grain  compound  jalap  powder,  combined  with  ^4  grain 
calomel,  may  be  given  on  awakening,  and  repeated  if  necessary  the  following 
morning ;  ^/og^  grain  phosphorus  dissolved  in  one-half  teaspoonf ul  of  cod- 
liver  oil  may  be  given  three  times  a  day  after  meals. 

The  diet  should  consist  of  skimmed  milk,  expressed  beef  juice,  chicken, 
or  lamb  broth  thickened  with  barley  or  farina,  steamed  rice  or  farina, 
arrowroot  boiled  in  milk,  puree  of  peas,  stewed  fruit,  bread,  crackers  and 
butter.  Meat  and  eggs  should  be  eliminated  from  the  diet.  Water  may 
be  given  liberally. 

Tetanus  (Lock  Jaw). 

This  acute  infectious  disease  is  caused  by  the  invasion  of  a  specific 
micro-organism. 

Etiolo^. — 'Any  open  wound  on  the  surface  of  the  body  can  be  the 
point  of  entrance  for  these  pathogenic  bacteria. 

There  are  some  parts  of  our  country  in  which  the  disease  exists  all 
the  year  round,  provided  the  factors  which  cause  the  same,  filth  and  dirt, 
are  brought  into  play.  A  child  infected  with  tetanus  can  transmit  the 
disease ;  hence  this  should  be  bcfme  in  mind  while  a  case  is  under  treatment. 

Bacteriology. — Nicolaier  in  1884  found  a  specific  micro-organism  in 
the  soil  from  which  he  infected  animals  and  produced  tetanus.  He  also 
found  this  germ  present  in  patients  affected  with  tetanus. 

In  1898  Kitasato  demonstrated  this  bacillus  in  pure  culture.  It  was 
also  found  in  infants  suffering  with  tetanus.  TVom  the  pure  culture 
Kitasato  and  Behring  produced  an  antitoxin. 

The  toxin  generated  by  tetanus  is  a  deadly  poison.  Kitasato  found 
that  an  animal  which  was  infected  and  left  alone  died  in  one  hour. 

.Pathology. — Distinct  lesions  of  tetanus  cannot  be  demonstrated  patho- 
logically. An  open  wound  and  evidences  of  a  general  septic  infection  can 
usually  be  found.  Hgemorrhages  of  the  brain  or  smaller  hsemorrhages  in 
various  parts  of  the  body  may  exist.  If  the  umbilicus  has  been  the  point 
of  entrance,  the  wound  will  not  heal. 

Symptoms. — In  the  new-born  the  first  symptom  noticed  is  the  refusal 
to  take  the  breast.  Owing  to  the  rigidity  of  the  muscles,  the  jaws  will  be 
-found  stiffened  and  feel  hard  to  the  touch.  The  same  spasmodic  stiffening 
will  be  made  out  in  the  other  parts  of  the  body.    After  a  sudden  stiffening 


TETANUS.  759 

the  muscles  usually  relax.  Muscular  rigidity  appears  in  paroxysms  and 
may  come  on  every  few  minutes. 

The  temperature  varies  between  101°  and  104°  F.  or  there  may  be 
hyperpyrexia  reaching  107°  F.  The  pulse  is  small,  feeble,  compressible,  and 
very  rapid.  Symptoms  of  malnutrition,  such  as  emaciation,  are  very  evi- 
dent. Stadtfeldt  reports  88  fatal  cases;  83  of  these  died  between  the  ages 
of  six  and  ten  days. 

The  following  case  illlustrates  tetanus  seen  in  private  practice : — 

A  female  infant  fifteen  days  old  was  seen  by  me  suffering  with  fever.  The 
nurse  said  that  she  refused  the  breast.  The  infant  was  in  good  health  apparently  up 
to  this  time.  The  appetite  was  good,  the  bowels  regular,  no  gastric  disturbances 
existed.  On  examination  the  umbilicus  was  found  inflamed  and  suppurating.  The 
temperature  was  102°  F.;  the  pulse  160.  The  jaws  were  fixed.  The  infant  had 
spasms,  which  grew  more  severe  when  she  was  handled.  The  body  relaxed  for  a 
few  minutes  at  a  time. 

The  treatment  consisted  in  cleansing  the  wound  with  strict  asepsis,  dusting 
europhen  powder  on  the  umbilicus,  and  protecting  the  same  with  a  sterile  bandage. 
The  rectum  and  colon  were  flushed  with  warm  saline  solution.  An  injection  of  5 
cubic  centimeters  of  antitetanus  serum  was  given  with  the  usual  antitoxin  syringe. 
As  no  effect  was  evident  from  the  injection,  a  second  injection  of  5  cubic  centimeters 
was  administered  twelve  hours  later.  Symptoms  of  improvement  followed  and  the 
child  recovered. 

A  second  case  of  tetanus  was  one  caused  by  scratching  an  open  wound  situated 
near  the  nose,  while  playing  with  a  canary  bird.  Symptoms  of  tetanus  appeared 
two  days  after  infection.  This  case  was  also  seen  in  consultation  by  Dr.  George  F. 
Shrady.  Large  quantities  of  tetanus  antitoxin  were  injected  with  no  beneficial 
result.  The  case  ended  fatally.  In  this  case  the  infection  was  traced  to  some 
canary  birds  which  were  in  the  same  room  as  that  occupied  by  the  family. 

Prognosis  and  Course. — The  duration  of  fatal  cases  is  seldom  more 
than  one  or  two  days.  Those  tending  to  recovery  usually  extend  from  one 
to  three  weeks. 

While  occasionally  cures  are  reported,  five  out  of  ten  seen  by  me  have 
ended  fatally.  I  have  seen  cases,  both  in  this  country  and  abroad,  injected 
with  sufficient  antitoxin,  end  in  recovery. 

Treatment. — An  injection  of  30  cubic  centimeters  tetanus  serum  should 
be  given,  and  repeated  every  twelve  hours  until  the  toxic  sjinptoms  improve. 
In  addition  thereto,  the  bromides  of  potassium  and  sodium,  chloral  hydrate, 
belladonna,  and  opium  are  among  the  anti-spasmodics  used.  It  is  essen- 
tial to  give  large  doses  or  no  effect  will  be  produced.  Calabar  bean  has  been 
lauded  by  some  authors  and  can  be  given  hypodermically. 

The  literature  records  a  great  many  cases  where  the  antitoxin  was  in- 
jected directly  into  the  brain.  In  the  new-bom  baby  this  method  should  be 
used,  as  there  is  no  obstacle  to  the  introduction  of  the  needle  through  the 
open  fontanel. 

Jn  one  case  treated  by  me  the  antitoxin  was  injected  through  the  ante- 
rior fontanel. 


760  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Epilepsy. 

Epilepsy  is  frequently  seen  in  very  young  children.  Some  writers  state 
that  it  develops  in  children  approaching  puberty.  I  have  seen  epileptic 
spasms  in  children  under  1  year  of  age. 

Etiolo^. — Children  whose  parents  are  drunkards,  or  where  nervous 
diseases  exist,  are  predisposed  to  this  condition.  According  to  Berkley,  33 
per  cent,  of  these  cases  give  a  historj^  of  alcoholism  in  one  parent.  Eachitic 
infants  are  frequently  seen  with  -epileptic  seizures,  so  that  it  is  quite  pos- 
sible that  they  are  predisposed.  Children  who  have  suffered  with  convul- 
sions in  early  life  frequently  have  epilepsy  later  in  life.  This  has  led  some 
authors  to  believe  that  convulsions  and  epilepsy  are  as  cause  and  effect. 

Undoubtedly  many  cases  of  this  kind  exist.  Statistics  prove,  how- 
ever, that  one-half  of  all  eclamptic  children  have  no  further  nervous  dis- 
eases in  later  life.  Hence,  we  must  not  claim  that  if  an  infant  suffers  with 
eclampsia  it  mtist  necessarily  hecome  an  epileptic. 

An  injur)'  to  the  head,  fright,  or  sunstroke  may  possibly  cause  this  dis- 
ease. Some  authors  state  that  epileptic  convulsions  are  intimately  asso- 
ciated with  adenoid  vegetations,  phimosis,  and  masturbation.  Foreign 
bodies  in  the  nose,  throat,  and  ear  may  occasionally  be  predisposing  factors. 
Other  writers  believe  that  menstrual  disorders  will  provoke  epilepsy. 

'The  etiolog}^  of  idiopathic  epilepsy  is  mainly  to  be  sought  in  alco- 
holism in  the  parents,  which  induces  a  defective  organization  of  the  brain 
structures  in  the  descendants.  Inherited  syphilis  is  a  less  frequent  factor. 
The  signs  of  inheritance  are  chiefly  seen  in  the  departure  from  the  normal 
in  the  skull  formation,  microcephalus,  macrocephalus,  as  well  as  asym- 
metries of  the  skull  and  facial  bones.  Flatness  of  the  cranial  arch  is  found 
in  a  considerable  proportion  of  epileptics,  particularly  among  the  males. 
Signs  of  rickets  are  especially  frequent  in  epileptic  children.  Aronsohn, 
in  a  study  of  heredity  among  508  epileptics,  found  a  history'-  of  neuro- 
pathic disease  in  the  parents  in  33  per  cent.  Females  showed  a  stronger 
tendency  to  inherit  the  disease  than  males,  33  per  cent,  against  30  per  cent. 
The  disposition  on  the  part  of  the  mother  to  transmit  epilepsy  is  greater 
than  that  of  the  father  (391/2  against  29  per  cent,  of  inherited  cases). 
Where  both  parents  were  hereditarily  burdened,  63  per  cent,  of  the  children 
inherited  the  disease.  In  82  per  cent,  of  the  inherited  cases,  the  disease 
began  before  the  twentieth  year  of  life.  Wildermuth,  in  145  cases  of  early 
epilepsy,  found  inherited  tendencies  in  49  per  cent.,  drunkenness  on  the 
part  of  the  parents  contributing  nearly  one-half  (21  per  cent.)  of  the 
examples.  Traumatism  in  early  life  furnishes  a  small  number  of  cases 
of  epilepsy.  Among  210  patients  assembled  by  Wildermuth  antecedent 
injury  to  the  head  had  occurred  eight  times.  In  the  majority  of  the  trau- 
matic cases,  the  seizures  followed  the  injury  within  a  few  days  or  weeks. 


EPILEPSY.  761 

seldom  after  months.  Epileptiform  seizures  and  their  sequelae  are  some- 
times found  where  there  has  been  antecedent  meningitis,  porencephalia,  or 
cerebral  haemorrhage  in  infancy;  they  may  also  result  from  acute  infec- 
tious processes,  but  in  these  instances  they  are  to  be  regarded  not  as  be- 
longing to  true  epilepsy,  but  as  the  symptomatic  expression  of  a  coarse, 
irritative  cerebral  lesion"  ('Eerkley). 

Pathology. — Gowers  states  that  the  disease  is  probably  located  in  the 
gray  matter  of  the  cortex.  It  should  be  regarded  as  a  muscular  spasm,  the 
result  of  the  sudden  overaction  or  discharge  of  the  nerve  cells.^ 

Of  1450  cases  of  epilepsy  studied  by  this  same  writer,  12  per  cent, 
began  during  the  first  three  years  of  life,  and  46  per  cent,  between  the 
tenth  and  twentieth  years. 

An  interesting  point  was  brought  out  by  Herter  and  Smith,^  who 
studied  238  specimens  of  urine  taken  from  31  epileptics. 

They  noticed  that  in  72  of  these  observations  there  was  excessive  in- 
testinal putrefaction,  as  shown  by  the  presence  of  ethereal  sulphates  in  the 
urine  jvst  before  the  occurrence  of  the  spasm.  These  authors  were  war- 
ranted, therefore,  in  their  conclusion,  that  there  is  a  distinct  association 
between  the  intestinal  poisoning  and  the  epileptic  seizures.  We  can  readily 
see  that  the  treatment  of  any  case  of  epilepsy  must  be  followed  along  the 
lines  just  described. 

Symptoms. — There  are  two  kinds  of  attacks  usually  met  with:  first, 
the  grand  mal;  second,  the  petit  mal. 

Grand  Mal  Form. — ^The  attack  may  come  on  gradually  or  it  may  be 
sudden.  Children  old  enough  to  complain  frequently  have  a  warning  of 
the  attack  known  as  the  aura.  This  aura  consists  in  a  series  of  symptoms, 
such  as  a  twitch  in  the  leg  or  the  face,  constituting  a  local  spasm  described 
by  some  authors  as  a  "motor  aura."  Then  again  there  may  be  abnormal 
sensations,  such  as  a  tingling  or  numbness  in  any  part  of  the  body,  until 
the  patient  suddenly  falls  with  the  spasm.  There  may  be  an  unusual 
tremor  or  a  shivering  sensation,  and  the  patient  may  fall  to  the  floor  with 
a  sharp  cry,  having  the  jaw  set  and  all  the  muscles  of  the  body  in  tonic 
spasm.  The  eyeballs  are  usually  rolled  upward.  After  a  few  seconds,  dur- 
ing which  the  skin  is  cyanotic,  a  second  stage  follows,  in  which  there  are 
clonic  spasms.  There  may  be  involuntary  spasms  of  the  bladder  and  bowel. 
In  the  clonic  stage  the  muscles  frequently  contract  and  relax  violently. 
Not  infrequently  the  tongue  is  apt  to  be  caught  between  the  teeth  and  is 
bitten.  There  may  be  frothing  at  the  mouth.  Very  marked  rigidity  of 
the  sterno-cleido-mastoid.  The  head  may  be  thrown  backward  or  it  may 
be  twisted  to  one  side.  The  extremities  may  relax  and  then  become  rigid 
again,  and  the  cyanosis  gradually  disappears.     Children  usually  fall  into 


^Gowers:    Diseases  of  the  Nervous  System,  Amer.  Ed.,  1888. 
*  New  York  Medical  Journal,  August  and  September,  1892. 


763  DISEASES  OF  THE  NERVOUS  SYSTEM. 

.  a  deep,  sleep  as  though  exhausted  after  the  end  of  the  clonic  stage.  This 
isleep  lasts  hours  at  times.  Children  old  enough  to  describe  symptoms  will 
jstafte  that, they  have  no  knowledge  of  what  has  happened.  They  awake  just 
as  children  do  after  a  deep  chloroform  narcosis. 

Petit  Mai  Form.- — This  is  a  milder  type  of  the  condition  above  de- 
scribed. The  attacks,  instead  of  lasting  minutes  and  hours,  usually  last 
but  a  few  seconds.  The  child  does  not  fall,  but  may  sit  quietly  during  the 
seizure  until  it  passes  off.       - 

An  aura  is  absent  in  this  condition.  ,  The  attacks  not  infrequently 
happen  several  times  a  day. ;  They  may  also  occur  at  night.  In  some 
children  we  have  both  varieties. 

Diiferential  Diagnosis. — Epilepsy  is  frequently  confounded  with  hys- 

.  teria.     In  hysteria  there  is  partial  consciousness.     In  epilepsy  there  is  a 

loss  of  consciousness.    The  biting  of  the  tongue  and  symptoms,  such  as  the 

nocturnal  appearance  of  the  attacks,  will  aid  in  establishing  the  diagnosis. 

There  is  usually  a  dilatation  of  the  pupils. 

An  epileptic  may  have  an  attack  in  inopportune  places,  such  as  the 
street  or  on  a  hot  stove,  whereas  a  case  of  hysteria  usually  selects  a  place 
indoors,  entirely  out  of  danger. 

Prognosis  and  Course. — This  disease  does  not  follow. a  regular  course. 
The  usual  interval  between  seizures  in  the  very  beginning  may  be  months. 
Eegular  intervals  of  epileptic  attacks  may  be  every  two  or  four  weeks.  In 
some  severe  cases  seen  by  me  the  attacks  came  on  every  day.  It  is  not 
unusual  for  epileptic  seizures,  to  come  at  night  only.  When  such  is  the 
case,  the  diagnosis  is  very  difficult. 

The  outcome  depends  on  the  condition  of  the  patient.  A  child  may  be 
seized:  with  an  attack  while  on  the  street  and  be  killed  by  an  accident.  In- 
stances are.  on  record  where  epileptics  have  fallen  into  the  water  ^nd  were 
asphyxiated  during  the  spasm.  Traumatic  epilepsy  will  occasionally  be 
cured  by  surgery.  Generally  speaking,  the  cases  of  epilepsy  seen  by  me  did 
not  do  well  Ts^ith  surgical  treatment. 

Treatment. — A  case  of  this  kind  should  never  be  left  alone,  owing  to 
the  danger  of  accident  during  the  epileptic  seizure.  If  a  cause  exists,  such 
a.s,  adLenoid  vegetations  or  phimosis,  the  same  should  be  radically  treated.  I 
hav^ej previously  mentioned  the  resultsipf  Porter's  examinations  of  the  urine; 
thus,' we  find, that  the  products  of  indigestion  are  usually  found  in  epilepsy. 
.  •  Dietetic ,  Treatment. — Arguing  from  this  point  of  view,  the  stomach 
and  bowels  must  not  only  be  constantly  supervised,  Wt  the  lightest  kind  of 
nutrition  that  will  yield  strength  shpuld  be  ordered.  The  action  of  the 
,1  bowels  must  be  frequent.     The  slightest  constipation  should  not  be  per- 

,  mitted.      -  .r:.;: 

Cereals,  vegetables,  and  fruits,  in  fact,  the  lightest  kind  of  dairy 
products,  should  be  ordered.    Meat  and  similar  stimulating  nutrition  should 


EPILEPSY.  763 

be  enjoined.  Water  and  liquids  should  be  freely  given.  Neither  alcohol, 
tea,  nor  coffee  should  be  allowed.    ,  ,,    ..;■,,■,-'   •  .,      jh-. 

Hygienic  Trea/men^.— Children  so  afflicted  should  be  kept  out  of  doors 
as  much  as  possible.  They  should  not  attend  schopl.  They  should  have 
cheerful  surroundings  and  avoid  all  .ii«=eless  e.\;citement.  They  should  be 
given  a  bath  daily  and  a  proper  amount  of  sleep. 

Drug  Treatment. — Sodium  bromide  seems  to  be  the  drug  par  excel- 
lence in  the  treatment  of  this  disease.  Children  can  take  as  large  if  not 
larger  doses  of  bromide  than  adults.  I  have  frequently  given  10  grains  of 
bromide  of  soda  to  a  child  1  year  old,  and  repeated  the  same  several  times 
a  day. 

We  must  study  the  tolerance  of  every  child  by  carefully  increasing 
the  dose  until  the  physiological  effect  of  the  same  is  produced.  Seguin 
advises  giving  large  doses  early  in  the  morning,  small  doses  during  the  day, 
and  large  doses  at  night.  The  reason  for  the  large  dose  at  niglit  is  the  fre- 
quency with  which  the  attacks  appear  in  the  night.  Belladonna  is  advised 
by  some  authors.     Chloral  hydrate  is   frequently  useful  \y.hen   combined 

with  the  bromides.    I  sometimes  use  arsenic  alone  "when  the  bromides  cause 

'-)..  —J  ... 

acne. 

Crotalin  is  the  dried  venom  taken  from  the  fangs  of  the  American 
rattlesnake.  It  is  well  spoken  of  by  some  writers  in  the  treatment  of  this 
disease.    It  is  injected  into  the  back  of  the  forearm  in  Vaoo-grain  doses. 

Restorative  treatment  should  be  combined  with  this  anti-spasmodic 
treatment.  The  system  should  be  st;-engthened  by  giving  iron  and  strych- 
nine. The  use  of  malt  extracts  and ,  codliver-oil  will  be  found  beneficial. 
Regarding  the  surgical  treatnient  of  epilepsy,  Sachs  says : — 

"In  a  case  due  to  a  traumatic  or  organic  lesion  an  early  operation  may 
prevent  the  development  of  cerebral  sclerosis.  If  an  early  operatiqn  is  not 
done,  the  occurrence  of  epilepsy  is  a  warning  that  secondary  sclerosis  has 
been  established  and  an  operation  may  prevent  it  from  increasing.  Opera- 
tion must  include  the  removal,  of  the  diseased  area;  here,  if  all  other  parts 
are  normal,  a  cure  m^y  result.  Under  favorable  conditions  a  few  cases  of 
epilepsy  may  be  cured  by  surgery  and  many  more  improved."    ,  - 

Surgical  Treatment. — Geo.  W.  Jacoby  advises  as  a  prophylactic  meas- 
ure to  operate  early,  that  every  head  injury  or  suspected  fracture ^should'be 
trephined.  Thus,  an  operation  is  indicated  in  suspected  organic  focal  dis- 
ease of  the  brain.  If  meningeal  haemorrhage  due  to,  traumatism  is  siis- 
pected,  an  operation  will  do  good  if  performed  early.  Concerniug  the  ex- 
cision of  a  piece  of  the  cortex  to  remove  a  scar,  he  does  not  believe  any 
permanent  benefit  is  derived  therefrom,  because  a  larger  scar  results. 

B.  Sachs  and  A.  Gerster^  give  the  following  summary:  An  opera- 
tion is  permissible  in  traumatic  epilepsy  when  the  case  is  not  over  1  or 


^American  Journal  Medical  Science,  October,   1896.       •  ■  r^o^.TST 


764  DISEASES  OF  THE  NERVOUS  SYSTEM. 

2  years  old.  When  there  is  a  depression  of  bone,  the  operation  is  indi- 
cated at  a  later  period,  but  should  not  be  delayed.  Trephining  alone  is 
sometimes  sufficient.  If  the  disease  is  of  short  duration,  a  part  of  the 
cortex  may  be  incised.  The  complication  of  infantile  cerebral  paralysis,  if 
the  case  be  recent,  is  no  contraindication  to  the  operation.  It  must  not  be 
performed  in  epilepsy  of  long  duration. 

Acute  Myelitis. 

This  condition  consists  in  a  diffuse  inflammation  resulting  in  destruc- 
tion of  spinal  elements  and  the  softening  of  the  cord. 

Etiology. — It  is  not  a  rare  condition,  but  is  most  frequently  seen  as  a 
complication  of  the  infectious  diseases.  Chilling  of  the  surface  of  the  body 
seems  to  favor  the  development  of  this  condition.  Some  authors  state  that 
it  follows  metallic  or  other  chemical  poisonings.  It  is  frequently  associated 
with  spinal  trouble,  such  as  Pott's  disease.  Injury  is  frequently  given  as 
a  cause,  hut  syphilis  is  the  most  frequent  cause. 

Pathology. — Macroscopical :  The  cord  is  seen  thickened  and  sur- 
rounded by  hypersemic  meninges.  The  substance  of  the  cord  is  much 
softer  than  normal  and  sometimes  resembles  pus.  Frequently  small,  punc- 
tate haemorrhages  and  even  larger  extravasations  of  blood  can  be  seen 
microscopically.  In  severe  disintegration  of  the  cord,  the  microscopical 
findings  are  useless.  It  is  in  the  mildest  forms  that  pathological  changes 
can  best  be  studied.  In  the  dilated  blood-vessels  we  find  leucocytes  and 
granules  of  myelin.    Corpora  amylacea  are  frequently  seen. 

Symptoms  and  Diagpiosis. — The  symptoms  depend  on  the  portion  of 
the  cord  tissue  involved,  and  on  the  severity  of  the  process.  In  syphilis  we 
have  a  slowly  developing  condition  weeks  and  months  before  myelitis 
symptoms  pointing  to  this  condition  can  be  noticed.  If  children  can 
complain  they  describe  a  sense  of  weight  in  the  legs,  which  gradually 
increases,  so  that  in  a  few  days  the  limbs  are  entirely  palsied.  Convulsions 
and  delirium  have  frequently  been  noted.  When  the  reflexes  are  anatom- 
ically related  to  the  affected  segments  they  disappear,  and  below  that  level 
they  are  increased;  after  a  few  days,  if  the  cord  has  been  entirely  de- 
stroyed at  the  inflammatoi'y  focus,  the  reflexes  are  entirely  abolished 
(Church).  Provided  the  posterior  roots  and  meninges  are  involved,  pain 
in  the  back  and  limbs  is  a  prominent  symptom,  but  rarely  is  of  an  ex- 
cruciating character  at  the  onset.  At  the  upper  level  of  the  inflammation 
some  pain  is  the  rule,  which  gives  rise  to  a  band  or  girdle  sensation  and  a 
zone  of  hypersesthesia  about  the  abdomen  or  chest.  This  sign,  with  the 
paralysis,  definitely  localizes  the  upper  limit  of  the  lesion,  but  if  it  be  in 
the  lower  cervical  region  this  sensation  passes  down  the  arms  and  is  not  so 
sharply  defined.  Lesions  in  the  cervical  region  are  also  marked  by  impli- 
cation of  the  cilio-spinal  center,  with  consequent  dilatation  of  the  pupil. 


ACUTE  MYELITIS.  765 

Continuous  priapism  is  then,  too,  a  usual  occurrence,  and  the  intercostal 
muscles  and  heart  may  be  affected.  Below  the  lesion,  and  depending  upon 
its  intensity,  there  are  variations  in  sensibility  to  all  forms  of  stimulation, 
from  slight  blunting  to  the  usual  complete  anaesthesia.  Sensations  of 
drowsiness  and  aching  in  the  paralyzed  and  anaesthetic  limbs  are  some- 
times mentioned;  and  cramps  and  drawing  up  of  the  limbs  frequently 
occur  early,  and  later  are  the  rule.  Distinct  muscular  atrophy  related  to 
the  portion  of  the  cord  affected  takes  place,  but  in  the  trunk  it  is  not 
readily  discernible.  The  paralyzed  limbs  during  the  first  few  days  are 
abnormally  warm,  but  soon  present  a  subnormal  temperature;  sluggish 
circulation  and  emaciation  ensue,  with  cedema  of  the  feet  and  legs  if  the 
limbs  are  left  any  length  of  time  in  a  pendent  position.  If  the  lesion  is  low 
down,  the  atrophy  is  a  marked  feature  and  the  reaction  of  degeneration  is 
present.  Under  the  influence  of  pressure,  bed-sores  form  on  prominent  por- 
tions of  the  body  and  limbs,  and  this  very  early.  In  some  cases  within  the 
first  week  immense  sphacelization  may  take  place  over  the  sacrum,  which 
cannot  be  explained  by  pressure  and  the  moisture  from  the  urine,  but  im- 
plies a  dystrophic  condition  of  cord  origin.  Trophic  symptoms  (bed-sores) 
are  especially  liable  to  occur  when  the  lumbar  cord  is  the  seat  of  the  disease. 

Prognosis  and  Course. — The  course  of  the  disease  is  chronic.  The 
condition  varies  but  little.  The  symptoms  get  worse  and  worse  until  death 
ends  the  trouble.  From  a  few  weeks  to  a  few  months  may  terminate  the 
disease. 

At  times  if  it  is  associated  with  or  dependent  on  Pott's  disease,  im- 
provement may  be  expected.  Sometimes  myelitis  is  caused  by  syphilis 
either  in  its  active  form  or  due  to  a  syphilitic  neoplasm.  It  is  rare  in  such 
conditions  to  effect  a  cure. 

Treatment. — If  specific  conditions  such  as  syphilis  exist,  then  anti- 
luetic  treatment  is  required.  Iodide  of  sodium  can  be  given  in  very  large 
doses,  5  to  50  grains  per  day.  The  general  indications,  such  as  attention  to 
the  stomach  and  bowels,  must  be  met  and  stimulated  if  required.  It  is  im- 
portant to  feed  a  patient  in  this  condition  with  very  nutritious  food.  Coun- 
ter-irritation over  the  spine  is  advisable.  For  this  purpose  tincture  of  iodine 
or  mustard  will  be  useful.  I  insist  on  absolute  rest  in  bed  (water  bed  if 
possible)  and  in  frequent  change  of  position. 

Ckronic  Myelitis. 

This  condition  is  usually  the  continuation  or  the  prolongation  of  acute 
softening  of  the  cord.  It  is  here  that  we  find  bed-sores  as  well  as  disturb- 
ances of  the  bladder  and  bowels. 

Treatment. — The  treatment  consists  in  what  has  been  previously  ad- 
vised in  the  acute  condition.  Life  can  only  be  prolonged  by  giving  tone  to 
the  system  with  proper  food. 


766  DISEASES  OF  TH-fe  NERVOUS  SYSTEM. 


.:   Malformation  of  the  Spinal  Cord  (Spina  Bifida). 

The  ihosi;  frequent  liialformation  seen  is  spina  bifida.  It  affects  the 
vertebral  canal  and.  ends  in  a  protrusion  of  a  small  or  large  soft  tumor  filled 
with  serum.  ,This  sermii  is  a  clear,  yellowish  liquid  similar  to  cerebro-spinal 
fluid.  We  are  indebted  t6  Humphrey^  for  an  accurate  description  of  this 
lesion.  He  says:' "Spina  bifida  is  due  to  an  early  failure  in  development, 
in  most  cases  before  the  cord  is  segmented  from  tlie  epiblastic  layer  from 
wliich  it  is  developed.  ,  Hence,  it  remains  adhereiit  to '  the  epiblastic  cov- 
ering, and  the  structures  which  should  be  formed  between  the  cord  and  the 


Fig.  251. — Case  of  Spina  Bifida.'  Spontaneous  cure.  Male  cliild,  6 
'  '-'-  years  old.  Now^,  suffers  with  paralj'-'Sis  of  both  legs.  Well  nourished.  No 
'T      evidence  of  hydrocephalus.     (Original.) 

skin  are  developed.  For  this  reason  we  have  in  the  wall  of  the  sac  a  fusion 
of  the  elements  of  the  cord,  nerves,  meninges,  vertebral  arches,  muscles,  and 
integument.  If  the  error  in  development  occurs  later,  the  cord  and  nerves 
may  be  attached  to  the  sac,  but  not  intimately  fused  with  it;  in  still  other 
cases  the  cord  does  not  enter  the  sac  at  all.  The  malformations  may  occur 
before  the  central  canal  is  cl(5sed,  or,  if  closed,  it  may  reopen  from  the 
accumulation  of  fluid.  It  is  probable  that  the  accumulation  of  fluid  first 
occurs,  and  that  this  prevents  the  union  of  the  parts  of  the  vertebral 
arches. 

"Although  the  tumor  is  generally  associated  with  a  bifid  spine,  this  is 
,not  necessarily  the  case.    The  protrusion  may  take  place  through  the  inter- 


^  Lancet,  March  28,  1885. 


HEREDITARY  ATAXY.  757 

vertebral  notch  or  foramen,  or  there  may  be  a  fissure  of  the  bodies  of  the 
vertebrae,  and  an  anterior  tumor  projecting  into  the  cavity  of  the  thorax, 
abdomen,  or  pelvis,  spina  bifida  occulta.  The  principal  anatomical  varieties 
are  meningocele,  meningo-myelocele,  and  syringo-myelocele." 

The  following  case  of  spina  bifida  occurred  in.  my  private  practice.  A  boy,  6 
years  old,  was  brought  to  me  with  a  history  of  having  a  very  large  growth  in  the 
lumbar  region.  The  sac  burst  spontaneously.  Since  that  time  the  boy  has  a  double 
paralysis,  and  also  suffers  with  incontinence  of  urine  and  fseces.  He  was  brought  to 
me  for  the  treatment  of  the  paralysis.  The  general  condition  was  good  and  he 
appeared  well  nourished.    There  was  no  evidence  of  hydrocephalus. 

Treatment. — ^The  treatment  of  spina  bifida  is  surgical.  I  have  seen 
a  number  of  successful  cases. 

Hereditary  Ataxy  (Friedreich's  Disease).^ 

This  condition  is  caused  by  degeneration  of  the  posterior  columns 
of  the  spinal  cord.    As  a  rule  several  members  of  the  family  are  affected. 

Etiology. — This  disease  is  usually  seen  at  or  about  the  period  of 
puberty.  Measles,  scarlet  fever,  or  any  other  acute  infectious  disease  may 
precede  the  development  of  this  condition. 

Pathology. — The  lesions  seen  are:  "Sclerosis  in  the  posterior  columns 
(columns  of  Groll  in  their  whole  extent,  and  columns  of  Burdach  in  their 
upper  part),  in  the  direct  cerebellar  tract  extending  laterally  into  the  column 
of  Gowers,  in  the  lateral  columns  (crossed  pyramidal  tracL),  in  the  gray 
matter  (columns  of  Clarke,  and  posterior  horns).  In  some  cases  dilatation 
of  the  central  canal  has  been  observed." 

Symptoms  and  Dia^osis. — The  motor  system  shows  tlie  most  charac- 
teristic symptoms.  The  patient  stands  with  the  feet  far  apart.  The  body 
sways  and  there  is  an  unsteadiness  while  trying  to  maintain  the  equilibrium. 
The  gait  resembles  that  of  an  alcoholic  intoxication.  A  tremor  of  the 
hands  and  head  and  choreiform  movements  affect  the  same  parts.  Paralysis 
and  emaciation  may  be  present.  The  tendon  reflexes  are  absent  as  a  rule, 
but  their  presence  does  not  speak  against  the  diagnosis  in  the  early  stage  of 
the  disease.  The  eyes  show  nystagmus.  There  is  no  optic  atrophy.  There 
is  vertigo.  The  speech  is  slow.  The  intellect  seems  impaired.  There  is  a 
peculiar  clubbing  of  the  feet.  The  foot  is  short.  The  toes  are  over- 
extended, the  instep  high  and  hollow.  The  Babinski  phenomenon,  or  hyper- 
extension  of  the  big  toe,  may  be  the  first  symptom  of  this  condition. 

The  prognosis  is  grave.    The  disease  lasts  years. 

Treatment. — The  disease  runs  its  course,  although  electricity  and 
restorative  treatment  plus  massage  may  be  tried.  The  disease  usually  ends 
fatally. 


^  I  am  indebted  to  Williams's   excellent  monograph  for   some   points   in   this 
article. 


768 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Poliomyelitis  (Infantile  Spinal  Paralysis). 

This  disease  is  characterized  by  a  sudden  onset  of  fever,  then  paralysis, 
usually  followed  by  muscular  atrophy  and  imperfect  bone  development, 
sometimes  by  deformity. 

The  recent  studies  of  Flexner  and  Koguchi^  show  that  poliomyelitis  is 
due  to  a  distinct  micro-organism  which  can  be  isolated  from  the  human 
poliomyelitic  virus.  The  micro-organism  exists  in  the  infected  and  dis- 
eased organs;  it  is  not,  as  far  as  is  known,  a  common  saprophyte,  or  asso- 
ciated with  any  other  pathological  condition;  it  is  capable  of  reproducing 
on  inoculation  the  experimental  disease  in  monkeys,  from  which  animals 
it  can  be  recovered  in  pure  culture.  Besides  these  classical  requirements, 
the  micro-organism  withstands  preservation  and  glycerination  as  does  the 


t 

<\.,g^i^g»||i^ 

Fig.    252. — Mi:ro-organism  Causing  Epidemic  Poliomyelitis.     Separate  Globoid 
Bodies.     X  1000.     (Courtesy  of  Dr.  S.  Flexner.) 


ordinary  virus  of  poliomyelitis  within  the  nervous  organs.  Finally,  the 
anaerobic  nature  of  the  micro-organism  interposes  no  obstacle  to  its  accept- 
ance as  the  causative  agent,  since  the  living  tissues  are  devoid  of  free 
oxygen  and  the  virus  of  poliomyelitis  has  not  yet  been  detected  in  the  cir- 
culating blood  or  cerebrospinal  fluid  of  human  beings,  in  which  the  oxygen 
is  less  firmly  bound,  nor  need  it,  even  should  the  micro-organism  be  found 
sometimes  to  survive  in  these  fluids. 

,  Now  that  the  specific  cause  of  infantile  paralysis  has  been  found,  it  is 
but  rational  to  assume  that  a  specific  serum  or  vaccine  will  be  made,  such 
being  possible,  we  may  then  hope,  with  specific  treatment  in  the  pre- 
paralytic stage,  to  prevent  the  paralysis. 

Childhood  is  the  age  most  susceptible  to  an  infection  of  poliomyelitis. 
During  the  epidemic  of  1916,  New  York  City  had  over  9000  cases.  The 
death  rate  was  about  26  per  cent.  Connecticut  and  Maine  each  has  nearly 
700  cases.  New  Jersey  about  3500  cases,  Pennsylvania  about  1300.-  cases, 
and  New  York  State,  exceluding-  New  York  City,  about  2800  cases. 


^Journal  of  Experimental  Medicine,  vol.  xviii,  No.  4,  1913. 


POLIOMYELTTTS. 


769 


Patholog-y. — One  of  the  facts  now  established  is  that  the  inflammation 
of  the  cord  is  always  accompanied  by  an  inflammatory  process  in  the  pia 
mater.  The  patholo<^ii-al  process  in  the  cord  itself  is  primarily  depejident 
upon  vascular  changes,  and  secondarily,  upon  changes  in  tlie  cells,  both 
ganglionic  and  interstitial.  The  vessels  of  the  cord,  medulla,  pons,  basal 
ganglia,  and  even  the  cerebral  cortex  are  dilated  and  engorged,  and  in  the 
cord,  medulla,  and  pons  the  capillaries  are  distended  to  more  than  twice 
tlieir  normal  caliber.  This  hyperaemia  is  found  at  all  levels  of  the  cord 
irrespective  of  the  intensity  of  the  other  inflammatory  changes.  It  is  now 
firmly  established  that  the  pathological  process  in  acute  poliomyelitis  is  one 
which  is  primarily  dependent  upon  the  vascular  and  interstitial  tissue 
changes  and  that  the  ganglion  cells  are  secondarily  affected.       (I.  Strauss.) 


1 — ee. 


Fig.  253. — Poliomyelitis.  Sclerosis  and  cicatricial  atrophy  of  the  left 
anterior  horn  of  the  fourth  cervical  nerve  after  acute  anteior  poliomyelitis. 
(a)  Nomal  anterior  horn  witli  ganglion  cells.  (6)  Atrophic  anterior  horn. 
( Ziegler. ) 


According  to  Peabody,  Draper,  and  Dochez,  "These  three  facts,  cellular 
exudate,  hoamorrhage,  and  edema,  .  ,  .  may  perhaps  be  regarded  as  the 
primary  reaction  of  the  nervous  system  to  the  virus  of  poliomyelitis.'"^ 
"...  the  damaging  effects  can  be  assumed  to  result  in  part  from  the 
direct  pressure  on  the  nerve  cells  of  hoemorrhages,  edema,  and  exudate." 
These  observations  were  made  at  autopsies. 

Symptoms  and  Diagnosis. — From  a  study  of  the  epidemic  prevailing 
during  the  summer  of  191G,  the  following  classification  seems  justifiable: — 

First.  T]ie  Ahortive  Type. — These  are  the  cases  responsible  for  the 
spread  of  the  disease,  for  the  large  majority,  owing  to  the  mildness  of  their 
symptoms,  are  passed  uimoticed.  They  may  be  termed  the  "carriers"  of 
this  infection. 

The  temperature  may  rise  no  higher  than  101  and  last  but  one  or  two 
days.    The  child  will  be  apathetic,  complain  of  headache,  and  have  extreme 

49 


770  DISEASES  OF  THE  NERVOUS  SYSTEM. 

lassitude.  He  may  also  complain  of  pain  in  tlie  arms  and  legs.  In  some 
forms  of  the  abortive  type  the  symptoms  will  pass  after  one  day,  the  child 
will  regain  his  appetite,  and  be  as  bright  as  usual.  The  reflexes  may  be 
slightly  exaggerated,  but  there  are  no  other  eyidences  of  paralysis. 

Second.  Gastroenteric  Type. — In  this  type  we  have  vomiting,  ano- 
rexia, fever;  temperature  ranging  between  102  and  105  degrees,  pulse  rang- 
ing between.  100  and  140,  extreme  lassitude,  pain  on  moving  the  arms  or 
legs,  pain  in  the  back  of  the  neck,  headache,  and  a  general  apathetic  condi- 
tion. The  sclera  of  both  eyes  show  engorged  blood-vessels,  the  eyes  stare 
or  are  fixed,  the  pupils  respond  slowly,  the  patellar  reflexes  are  exaggerated 
or  are  lost,  the  child  appears  to  be  in  a  stupor  or  semicomatose  condition, 
"usually  followed  by  paralysis. 

Third.  Respiratory  Type. — In  the  milder  forms  of  this  type  we  have 
symptoms  resembling  rhinitis  with  fever  ranging  between  103  and  104 
degrees,  cough,  peevishness,  restlessness,  and  general  prostration.  In  the 
severer  forms  we  have  symptoms  resembling  bronchopneumonia :  high  fever; 
shallow,  frequent  respirations  ranging  between  50  and  80  per  minute,  pulse 
of  130  to  150  per  minute,  extreme  lassitude,  weakness  or  absence  of  knee- 
jerk,  and  evidences  of  profound  toxsemia.  Paralysis  of  the  respiratory  cen- 
ters frequently  follows. 

Fourth.  Bulbar  Type. — In  the  bulbar  type  we  have  inability  to  swal- 
low or  speak,  marked  rigidity  of  the  sternocleidomastoids,  with  intense  pain 
in  the  head  and  neck,  moaning  usually  preceded  by  convulsions,  both  tonic 
and  clonic  in  character.  The  muscular  system  of  the  arms  and  legs  show 
intense  rigidity.  The  Kernig  sign  is  sometimes  present,  and  more  fre- 
quently marked  hyperextension  of  the  big  toe  (Babinski)  is  noted.  The 
pupils  respond  sluggishly  and  are  unusually  contracted.  AH  the  symptoms 
of  a  meningitis,  such  as  a  tache  cerebrale  and  Brudzinsky's  sign  described 
elsewhere  are  present.  In  the  early  stages  the  patellar  reflexes  may  be 
slightly  present,  but  later  are  absent.  The  plantar  reflex  is  usually  present. 
The  cremaster  reflex  slightly  present.  Paralysis  usually  takes  place  after 
the  febrile  condition  subsides.  The  duration  of  the  fever  is  from  three  to 
six  days,  although  I  have  seen  cases  in  which  the  fever  persisted  ten  days. 

Preparalytic  Symptom. — During^  the  febrile  stage,  if  the  child  is  care- 
fully observed,  we  can  frequently  note  an  important  symptom  which  has 
been  described  by  Colliver^  as  a  preparalytic  symptom.  It  is  a  peculiar 
twitching,  tremulous  or  convulsive  movement.  It  usually  affects  a  part  of 
whole  of  one  or  more  limits,  the  face  or  jaw.  It  may  also  affect  the  whole 
body.  In  the  beginning  the  symjitoms  may  last  less  than  one  second,  and 
may  not  recur  oftener  than  every  hour  or  so.  Later  the  spells  lengthen  to 
a  few  seconds,  and  recur  at  shorter  intervals.    The  condition  is  sometimes 


^Journal  of  the  Amer.  Med.  Assoc,  March  15,  1913. 


POLIOMYELITIS. 


771 


accompanied  by  a  peculiar  cry,  similar  to  the  hydrocephalic.  During  the 
convulsive  movement  the  child  is  apparently  unconscious,  with  eyes  set  for 
a  few  seconds.  A  similar  symptom  has  been  described  by  Professor  ^'ette^,l 
of  Paris.  This  preparalytic  symptom,  if  noted,  will  serve  as  a  warning  of 
the  approaching  paralysis,  and  when  observed,  the  limb  should  be  strength- 
ened by  support. 


Fig.  254. — Paralysis,  of  the  muscles 
of  the  back,  trunk,  and  neck.  Cannot 
sit  unsupported.      (Original.) 


Fig.  255. — Paralysis  of  the  spinal 
muscles.  Intercostals,  showing  in- 
volvement of  the  serratus  magnus. 
(Orignal.) 


Eruption. — In  many  cases  a  pin-point  erythema  (scarletiniform)  scat- 
tered over  the  chest,  abdomen,  and  flexor  surfaces  of  arms  was  seen.  Some- 
times the  rash  appears  as  urticarial  blotches  or  wheals,  principally  on 
abdomen,  back,  thighs,  and  arms.  In  these  cases  toxic,  gastric,  or  gastro- 
enteric symptoms  are  found.  Another  type  of  eruption  seen  is  the  mor- 
billiform type.  The  eruption  crescentic  in  character  is  found  on  face,  neck, 
thorax,  and  a  few  scattered  areas  are  seen  on  the  arms  and  legs.  The  erup- 
tion usually  lasts  from  tlii'ee  to  ten  days,  and  fades  with  the  fever, 

'  British  Jour,  of  Children's  Diseases,  Dec,  1913. 


772  DISEASES  OP  THE  NERVOUS  SYSTEM. 

Lumbar  puncture^  should  be  made  to  verify  the  diagnosis.  Fifteen  to 
25  cubic  centimeters  of  spinal  fluid  should  l)e  withdrawn.  If  the  fluid 
comes  out  under  great  pressure,  then  50  to  100  cubic  centimeters  may  be 
withdrawn. 

According  to  the  findings  of  the  New  York  Board  of  Health,^  the 
spinal  fluid  in  poliomyelitis  is  usually  clear  and  increased  in  amount.  The 
albumin  and  globulin  are  increased  in  varying  degrees,  and  there  is  usually 
a  good  reduction  of  Fehling-^s.  The  cellular  increase  ranges  from  slightly 
above  normal  to  over  900  cells  per  cubic  centimeter.  Early  in  the  disease 
the  cells  may  be  50  per  cent,  or  more  mononuclears.  Later  there  is  usually 
90  per  cent,  or  more  mononuclears.  There  are  frequently  large  mononu- 
clear cells  that  seem  somewhat  characteristic  of  these  fluids. 

Treatment. — Through  the  needle  left  in  situ  Meltzer  advises  the  injec- 
tion of  2  c.c.  of  a  1 :  1000  adrenaline  solution.  The  adrenaline  injection 
may  be  repeated  every  four  hours  during  the  first  day,  and  if  improvement 
is  noted,  every  six  hours,  and  later  every  twelve  hours  on  successive  days. 

Muscular  rigidit}^,  accompanied  by  pain,  is  best  relieved  by  warm  sul- 
phur baths.  The  crude  sul|)huret  of  potassium,  4  ounces  to  a  tub  bath  at 
a  temperature  of  103°,  will  frequently  relax  the  body  and  promote  sleep. 
In  some  cases  it  will  be  found  necessary  to  prolong  the  bath  fifteen  to 
twenty  minutes  to  produce  an  effect.  These  baths  should  be  given  morning 
and  evening  for  at  least  one  week. 

Serum  Treatment. — ^Fifteen  cubic  centimeters  of  blood  serum  from  a 
convalescent  or  immunized  case  of  poliomyelitis  should  be  injected  intra- 
spinally  by  the  gravity  method  as  soon  as  procured.^  One  injection  of, 
serum  is  usually  sufficient,  although  the  same  dosage  may  be  repeated  in 
twenty-four  hours  if  no  improvement  is  noted.  I,  have  used  intraspinal 
irrigations  of  normal  saline  solution  at  a  temperature  of  110°  to  112°  in  a 
series  of  cases  with  excellent  result.  Several  moribund  cases  responded 
promptly  to  this  form  of  treatment.  The  needle  is  introduced  between  the 
fourth  and  fifth  lumbar  vertebrae,  and  as  much  as  possible  of  the  spinal 
fluid  withdrawn.  Thirty  to  100  cubic  centimeters  have  been  withdrawn  at 
one  time.  After  draining,  30  cubic  centimeters  of  the  saline  solution  is 
injected.  This  is  repeated  three  times.  After  the  third  drainage,  15  cubic 
centimeters  of  blood  serum  from  a  convalescent  case  is  injected,  the  needle 
withdrawn,  and  the  puncture  sealed  with  a  drop  of  collodion  or  medicated 
adhesive  plaster. 


'  Tlie  technique  and  illustration  of  lumbar  puncture  is  described  on  page  789. 

''Josephine  B.  Neal,  Archives  of  Pediatrics,  August,  1916. 

''This  method  was  advocated  by  Dr.  Aj  Zingher,  of  the  New  York  Board  of 
Health,  Research  Department,  during  the  epidemic  of  1916.  I  have  had  excellent 
results  with  the  same. 


POLTOiMYKLITIS. 


773 


In  tlie  bulbar  type  witli  extreme  prostration  and  coma,  where  it  was 
impossible  to  feed  by  mouth,  I  liave  used  injections  of  warm  saline  solution, 
250  cul)ic  centimeters,  every  four  to  six  hours,  by  hypodemioclysis.  In  one 
ease  of  coma  with  inability  to  swallow  the  child  received  250  cubic  centi- 
meters of  saline  solution  in  the  loose  cellular  tissue  of  the  abdomen  with 
excellent  results.  Hot  saline  colonic  flushings  at  a  temperature  of  110°  to 
115°  were  given  to  su])plement  the  hypodermoclysis. 


Fig.  256. — Paralysis  of  the  left  leg  and  foot.  Typical  drop-foot.  Note 
position' of  the  foot  in  standing — dne  to  paralysis  of  the  quadriceps  muscles. 
(Original.) 


In  older  children  ^'^musclc  training'^  is  conunended  and  the  child 
guided  through  aeti\e  exercises,  so  that  atrophy  from  non-use  is  prevented. 

A  comparison  of  this  latter  method  of  muscle  active  treatment,  rather 
than  the  muscle  passive  treatment,  which  latter  results  from  splints,  braces, 
and  plaster  casts,  shows  a  decided  leaning  toward  the  muscle  active  treat- 
ment. Patience  and  persistence  will  be  rewarded  by  success  after  weeks 
and  months  of  this  treatment.  The  child's  brain  must  be  in  sympathy 
with  its  movements;  hence,  the  passive  exercises,  such  as  gjTiinastics  or 
massage,  are  far  inferior  to  a  method  by  which  the  child  can  be  instructed 
in  the  performance  of  various  exercises   in  wliich  the  body   and  mind 


774  DISEASES  OF  THE  NERVOUS  SYSTEM. 

• 

co-ordinate.  It  has  been  found  by  clinical  experience,  and  such,  cases  have 
been  reported  by  Teschner  and  others,  that  a  muscle,  be  it  ever  so  atrophied, 
can  be  redeveloped  by  a  system  of  carefully  planned  exercises.  Electricity 
or  galvanic  current'  may  be  used  in  conjunction  vs^ith  massage,  but  gentle 
massage  will  accomplish  just  as  much,  and  more  than  violent  rubbing  by 
inexperienced  hands. 

Medicinal  Treatment. — Intramuscular  or  intravenous  injections  of 
one-half  the  usual  dose  of  salvarsan  given  as  a  restorative  may  be  tried. 
The  dose  should  be  repeated  every  week  until  the  systemic'  effect  of  the  sal- 
varsan is  manifested.  Intramuscular  injections  of  strychnine  in  doses 
of  ^/loo  grain  every  other  day  gradually  increased  until  ^/go  grain  can  be 
given  to  a  child  5  years  old,  younger  children  in  proportion.  Arsenic  in  the 
form  of  Fowler's  solution  may  be  given  in  doses  of  I  to  5  drops  three  times 
a  day. 

The  treatment  must  be  directed  toward  elimination  of  toxin  as  much 
as  possible.  Urotropin  (which  liberates  formaline)  may  be  given  in  2-  to 
3-  grain  doses  several  times  a  day.  Hot  packs  over  the  affected  parts  have 
a  stimulating  tendency. 

Bestorative  treatment  should  consist  in  giving  concentrated  food,  such 
as  milk,  yolk  of  egg,  broth,  and  gruel.  Seabaths  will  aid  in  restoring  normal 
conditions.    The  treatment  must  be  persisted  in  for  months. 

Prevention  of  Drop-foot. — ^\Vhen  it  is  evident  that  a  group  of  muscles 
is  weakened,  a  support  is  necessary.  Tubby  says  that  recovery  is  always 
hindered  and  even  entirely  prevented  in  a  stretched  muscle,  whereas  when  it 
is  relaxed  the  reverse  is  the  case.  Therefore,  in  order  to  obtain  the  best 
result  in  an  affected  muscle,  relax  it  to  its  fullest  extent  and  massage  it. 

Elongated  muscles  are  earliest  restored  to  j)ower  and  use  by  maintain- 
ing them  slack.  Muscles  not  paralyzed  will  contract.  George  W.  Jacoby 
recommends,  as  a  prophylaxis  for  drop-foot,  placing  the  foot  in  rectangular 
position  by  means  of  bandages  and  splint  to  prevent  contracture.  Never 
even  allow  the  weight  of  bed  clothes  on  the  foot. 

In  cases  of  drop-foot  or  drop-wrist,  tenotomy  may  be  required,  but 
this  should  be  left  to  the  judgment  of  a  conservative  orthopaedist.  Muscle 
transplantation  is  advised  after  paralysis  is  firmly  established. 

Eeb's    Palsy. 

This  is  commonly  known  as  obstetrical  paralysis,  and  is  caused  by 
pressure  exerted  on  the  brachial  plexus  during  birth.  One  or  both  arms 
may  be  involved. 

Brachial  plexus  paralysis  is  amenal^le  to  treatment.  An  interesting 
case  of  this  kind  occurred  in  the  practice  of  Dr.  D.  P.  Waldman,  of  this 
cit}',  with  whom  I  saw  the  case  in  consultation.    The  infant  was  bom  after 


fllllOXIC   IXTEliNAL  ]ni)ll(»("KI'llAIAS. 


775 


Fig.  257. — Case  of  Chronic  Internal  Hydrocephalus.  Note  the  position 
of  the  eyes  and  the  globular  shape  of  the  head.  Aspiration  of  the  ventricles 
every  week  gave  50  to  60  cubic  centimeters  of  a  perfectly  clear  fluid. 
(Uriginal.) 


Fig.    258. — Front  view  of  same  case.     Note  position  of  eyes  and  ears. 
This  is  a  characteristic  expression  of  hydrocephalus.      (Original.) 


776  DISEASES    OF    THE    NERVOUS    SYSTEM. 

an  unusually  protracted  labor  with  complete  unilateral  paralysis  involving 
the  right  arm.  With  the  aid  of  general  manipulation  and  faradic  elec- 
tricity the  case  completely  recovered.  The  duration  of  the  attack  was,  from 
onset  to  cure,  about  three  months. 

Treatment. — The  treatment,  as  a  rule,  consists  in  using  gentle  massage 
daily ;  also  a  mild  faradic  current  every  other  day.  If  there  is  no  response 
to  tills  treatment  within  ten  days  the  galvanic  current  should  be  tried.  Tub 
baths  at  temperaure  of  102°  F.  duration  one  minute  should  be  given  prior 
to  each  massage. 

Hydrocephalus. 

This  is  an  accumulation  of  serum  in  the  head. 

External  Hydrocepltalus. — ^^"hen  the  effusion  is  between  the  dura 
mater  and  the  pia. 

Internal  Eifdrocephalus. — When  the  lesion  is  in  the  ventricles  of  the 
brain.    The  latter  condition  is  most  commonly  seen. 

Acute  Hydrocephalus. 

This  condition  usually  follows  basilar  meningitis.  In  acute  hydro- 
cephalus the  effusion  is  not  large.  Some  authors  state  that  no  more  than 
three  or  four  ounces  of  serum  are  present. 

Cheoxic  Ikterxal  Hydrocephalus  (Water  on  the  Bbain). 

This  condition  must  not  be  confounded  with  tubercular  meningitis. 

Etiolog'y. — ^The  cause  of  primai^ror  secondary  internal  hydrocephalus 
is  very  difficult  to  determine.  In  some  instances  syphilis  has  been  given  as 
the  causative  factor.  An  interesting  paper  has  appeared  by  D^ Astros,^ 
who  describes  12  cases  in  which  hydrocephalus  was  associated  with  syph- 
ilitic lesions,  so  that  the  condition  was  congenital.  By  some,  chronic  hy- 
droeei^halus  is  believed  to  be  due  to  tuberculosis. 

Pathology. — "The  changes  in  the  brain  result  from  the  gradual  accu- 
mulation of  fluid  in  tlie  ventricles.  The  septum  lucidum  is  usually  broken 
down,  and  all  the  avenues  of  communication  between  the  ventricular  cav- 
ities are  greatly  enlarged.  The  continuous  distention  results  in  a  gradual 
thinning  of  the  brain  substance  which  forms  the  ventricular  walls;  often 
these  are  found  only  one-fourth  of  an  inch  in  thickness,  or  even  less  than 
this,  the  cortex  being  a  mere  shell." 

The  brain  appears  anseraic,  so  that  the  gray  and  white  substances  re- 
semble each  other.  The  bones  of  the  skull  show  the  lesions  very  plainly. 
The  sutures  are  separated  in  some  cases.  Where  premature  ossification  has 
taken  place,  the  head  instead  of  being  very  large,  is  very  small.  This  is 
called  a  microcephalic  condition.  Sometimes  spiua  l3ifida  is  associated  with 
this  condition. 


^Kevue  Mensuelle  des  Maladies  de  1'  Enfancej  Chapter  IX,  pp.  481  and  543. 


HYDROCEPHALUS. 


777 


Symptoms. — Tlie  first  symptoms  that  attract  attention  are,  that  the 
head  is  increasing;  in  size;  that  it  seems  very  heavy;  that  the  chihl  appears 
stupid';  tliat  it  does  not  notice  things,  but  stares  continuously.  The  fore- 
head is  very  high,  the  lontanel  (listended  and  bulging.  On  palpating,  the 
soft  fluctuating  liquid  can  be  felt.    The  sutures  are  very  wide  apart.    The 

pupils  are  usually  enlarged,  some- 
times contracted.  Convulsions  are 
frequently  present.  While  the  head 
enlarges  the  body  emaciates. 

Prognosis  and  Course.^ — ^This  dis- 
ease usually  terminates  fatally  al)out 
the  seventh  year.  In  rare  instances 
the  condition  may  extend  through  life 
with  impaired  mental  faculties  due  to 
the  brain  trouble.  Cases  that  have 
been  reported  cured  should  be  viewed 
with  suspicion. 

Treatment. — Aspiration  has  been 
tried  by  many,  with  no  apparent  bene- 
fit. I  have  never  seen  a  good  result 
follow  the  aspiration  of  the  liquid,  be- 
cause the  fluid  returns  very  rapidly, 
so  that  nothing  is  gained  by  the 
operation. 

Blistering,     counter-irritation, 
strapping,   and  lumbar  puncture  have 
been   tried   by   me  with   no   apparent 
success.     Iodoform  collodion  has  been  recommended  by  some. 

In  a  ease  seen  in  consultation  with  Dr.  L.  Harris,  of  this  city/convulsions  were 
relieved  by  lumbar  puncture. 

Jlereurial  inunctions  and  large  doses  of  iodide  have  been  tried.  If 
s.yphilis  is  the  cause,  then  some  benefit  may  be  expected  from  specific 

treatment. 

Meningocele. 

When  there  is  defective  ossification  in  the  bones  of  the  skull  and  some 
l)art  of  the  membranes  of  the  brain  protrudes,  it  is  called  a  meningocele. 
Some  writers  believe  it  is  caused  by  an  intra-uterine  hydrocephalus.  These 
tumors  generally  contain  cercbro-spinal  fluid  in  the  bag  of  membrane. 
When  pressure  is  exerted  over  the  swelling,  the  liquid  will  be  emiitied  into 
the  brain.  Sometimes  cerebral  symptoms  will  result  from  this  mani- 
festation. 

Encepiialocelb  (Cerebral  Hernia). 

In  this  condition  there  is  a  protrusion  of  the  brain  substance  in  addi- 
tion tatlie  membrane.    This  protrusion  takes  place  tiirough  the  frontal  and 


Fig.  259. — Hydroceplialic  cal- 
variuni  (or  skull-cap),  widely  gaping 
fontivnels  and  sutiires.  One-half 
natural  size.      ( Langerhans. ) 


778 


DISEASES   OF    THE    NERVOUS    SYSTEM. 


occipital  bones.  It  is  ■usually  a  congenital  deformity.  If  the  tumor  con- 
tains a  portion  of  a  dilated  ventricle  and  is  filled  with  cerebro-spinal  fluid, 
it  is  called  a  hydro-encephalocele  or  hydro-encephalo-meningocele. 

A  case  of  this  kind  was  seen  by  me  some  time  ago  in  which  the  tumor  protruded 
through  the  occipital  bone.  It  was  a  congenital  deformity.  Distinct  pulsation  could 
be  felt.  The  tumor  increased  in  size  when  the  child  cried.  Convulsions  resulted  from 
forcibly  pushing  the  tumor  into  the  cranial  cavity. 


Fig.  260. — Ericephalocele.  Infant  1  day  old,  admitted  to  my  hospital 
service,  having  a  globular  tumor  in  the  occipital  region  of  the  head.  The 
tumor  measured  SYo  centimeters  from  above  downward,  and  8%  centimeters 
from  side  to  side.  The  autopsy  was  performed  by  Dr.  John  Larkin. 
(Original.) 

Treatment. — 'The  injection  of  1  drachm  of  Morton's  fluid  after  aspira- 
tion of  some  of  the  liquid  contents  may  be  tried.    Morton's  fluid : — 

IJ   Kali    iodide    30  grains 

Iodine  pure .    10  grains 

Glycerine    1  ounce 

M.     Inject  1  drachm  after  each  aspiration. 

If  no  improvement  is  noted  after  some  time,  surgical  treatment  should 
be  tried. 

Ctclops. 

This  is  a  very  rare  condition  and  consists  of  the  child  having  but  one 
orbit,  which  is  situated  in  the  middle  of  the  forehead  at  the  root  of  the 
nose. 

PORBKCEPHALY. 

This  consists  usually  of  a  defective  development,  leaving  a  hole  in  the 
brain.  It  is  a  congenital  disease  and  may  be  located  in  any  portion  of  the 
brain. 


CHAPTEK  lY.       ' 

TUBERCULAR  MENINGITIS   (BASILAR  MENINGITIS). 

This  is  usually  a  secondary  condition.  It  is  not  a  primary  disease  of 
the  meninges.  In  infants,  tubercular  meningitis  usually  follows  bone  tu- 
berculosis, tuberculosis  of  the  lymph  nodes  or  joints,  and  not  infrequently 
a  tubercular  otitis  may  extend  and  involve  the  meninges. 

Etioiogy. — The  association  of  adenoid  vegetation  and  the  probable 
entrance  of  the  tubercle  bacillus  through  the  lymph  channels  of  the  neck 
is  the  most  probable  means  of  infection.^  (See  article  on  "Acute  Tubercu- 
losis.") 

Bacteriology. — There  is  no  question  about  the  association  of  the 
tubercle  bacillus  with  this  infection.  It  can  be  found  in  the  spinal  fluid 
withdrawn  by  a  lumbar  puncture.  Other  pathogenic  bacteria  may  also  be 
found.  In  one  case  reported  by  me  we  foimd  the  diplococcus  intracellularis 
in  addition  to  the  tubercle  bacillus. 

Pathology. — The  chief  pathological  condition  is  a  growth  of  miliary 
tubercles.  Associated  with  these  we  frequently  find  tubercular  nodules  of 
variable  size,  and  in  almost  every  case  they  are  the  products  of  ordinary 
inflammation  of  the  pia  mater — hTuph  or  pus — ^together  with  an  accumu- 
lation of  fluid  in  the  lateral  ventricles  of  the  brain.  Holt  says :  ^'Frequently 
there  are  tubercles  in  the  pia  mater  of  the  upper  portion  of  the  cord.  The 
miliary  tubercles  appear  as  small  gray  or  white  granules,  situated  along  the 
vessels  of  the  pia  mater.  When  few  in  number  they  are  usually  located  at 
the  base,  especially  along  the  Sylvian  fissures  and  in  the  interpeduncular 
space.  When  numerous,  they  are  most  abundant  at  the  base,  but  are  also 
seen  scattered  over  the  convexity  in  small  groups.  In  about  half  of  my 
autopsies  they  have  been  limited  to  the  base,  and  in  no  case  were  they  seen 
exclusively  at  the  convexity.  Tubercles  are  often  found  in  the  choroid  coat 
of  the  eye.  The  amount  of  lymph  and  pus  present  is  rarely  great,  and 
never  ecjual  to  that  seen  in  simple  acute  meningitis.  It  is  often  a  matter 
of  surprise  at  autopsies  to  find  the  lesions  so  few,  after  verv  marked  symp- 
toms. The  inflammatory  products  are  most  abundant  at  the  base.  In  addi- 
tion to  the  patches  of  greenish-yellow  lymph,  there  are  adhesions  between 
the  lobes  of  the  brain  and  thickening  of  the  pia.  In  cases  which  have  lasted 
for  several  weeks,  the  pia  mater  in  places  is  often  very  much  thickened. 


'■This  view  is  maintained  by  W.  Freudenthal,  of  New  York. 

(779) 


780 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


owing  to  cell  infiltration  and  the  production  of  new  connective  tissue,  and 
it  is  studded  with  miliary  tubercles,  sometimes  with  small  yellow  tuber- 
culous nodules;  frequently  there  is  arteritis,  which  is  sometimes  obliterat- 
ing. 

"In  the  most  acute  cases  the  brain  substance  immediately  beneath  the 
pia  is  intensely  congested,  slightly  softened,  and  shows  under  the  micro- 
scope a  superficial  encephalitis.  The  lateral  ventricles  "are  usually  distended 
with  clear  serum, .  sometimes  with  serum  containing  flocculi  of  lymph  or 


Fig.  261. — Tuberculous  Spinal  Meningitis.  Longitudinal  Section  of 
Spinal  Cord  and  Posterior  Roots,  (a)  Spinal  cord;  (&)  pia  mater;  (c) 
subarachnoidal  space;  {d)  arachnoid;  (e)  posterior  roots,  cellular  infiltra- 
tion and  containing  isolated  swollen  axis  cylinders;  (f)  vessel  with  cellular 
infiltration  and  proliferated  wall;  (g)  cellular  exudate  in  subarachnoidal 
space;    (i)  swollen  axis  cylinder.    X45.     (Ziegler.) 

pus;  the  amount  present  varies  from  one  to  four  ounces  in  each  ventricle, 
being  always  greater  in  the  subacute  cases.  The  walls  of  the  ventricles  may 
be  softened.  The  distention  of  the  ventricles  leads  to  flattening  of  the 
convolutions  from  pressure  against  the  skull,  to  bulging  of  the  fontanel, 
and  sometimes  to  separation  of  the  sutures,  if  they  are  not  completely  ossi- 
fied." 


PLATE  XXXVII 


Disseminated  Pulmonary  Tuberculosis  in  a  Two-year-old  Child  having  Tubercular^ 
Meningitis.     (Courtesy  of  Dr.  Wm.  H.  Stewart.) 


TUBERCULAR    MENINGITIS.  781 

Tuberculous  nodules  varying  in  size  from  a  small  pea  to  a  walnut  are 
frequently  seen  associated  with  meningitis  in  older  children,  but  not  so 
often  in  infants.  These  nodules  may  be  connected  with  the  meninges,  or 
they  may  be  situated  within  the  brain  substance,  usually  in  the  cerebellum. 
The  larger  ones  are  classed  as  brain  tumors.  Inflammatory  products  are 
rarely  found  in  the  spinal  canal. 

Course. — The  course  of  tubercular  meningitis  is  from  three  to  ten 
days,  although  the  symptoms  may  last  from  four  to  eight  weeks,  or  even 
longer. 

Child  B.  W.,  5  years  old.  Father  a  physician  and  healthy.  Mother  healthy. 
Had  just  returned  from  the  country  in  apparent  good  health.  Was  sent  to  school 
and  seemed  bright  mentally  and  physically.  Was  a  well-nourished  child.  Had 
had  no  previous  illness  excepting  a  disordered  stomach.  The  first  symptom  of  her 
present  illness  was  headache.  Had  a  coated  tongue,  loss  of  appetite  and  a  slight  rise 
of  tenipei-ature,  from  100°  to  101°  F.  The  temperature  was  very  characteristic.  (See 
chart.)  The  parents  suspected  a  slight  dyspeptic  attack  and  gave  her  a  laxative. 
Her  diet  was  also  corrected.  In  spite  of  cleansing  the  stomach  and  bowels,  the 
headache  persisted  and  reached  such  an  acute  stage  that  the  child  cried  and  moaned 
continuously,  and  did  not  sleep.  When  I  first  saw  the  case  the  symptoms  of  an 
acute  gastric  catan-h  were  so  evident  that  nothing  further  was  suspected.  The 
headache  persisted  in  spite  of  bromides.  The  child  complained  of  ringing  in  the 
ears.  Had  twitchings  of  the  arms  and  legs.  The  bowels  assumed  a  normal  color 
and  consistency.  An  examination  of  the  eyes  with  the  ophthalmoscope  was  first 
made  by  Dr.  H.  Jarecky  and  later  by  Dr.  Henry  S.  Oppenheimer,  who  found  vision 
good,  no  choked  disk — engorgement  of  veins  only — slight  reaction  of  pupils.  No 
evidence  of  tubercular  disease  was  found.  In  the  beginning  of  this  illness  the 
symptoms  of  headache  were  very  prominent.  The  child  appeared  quite  rational  and 
the  diagnosis  of  supra-orbital  nfuralgia  was  made.  Dr.  George  W.  Jacoby,  who  saw 
the  case  at  my  request,  early  in  the  disease  believed  that  we  were  dealing 
with  meningitis.  Later  on,  however,  the  symptoms  were  positive.  Dr.  Abraham 
Jaeobi,  who  saw  this  case  later  in  consultation,  diagnosed  meningitis.  At  his 
suggestion  leeches  were  applied  and  they  afforded  quite  some  relief.  The  head- 
ache reappeared  with  renewed  vigor  and  remained  incessant  throughout  the 
period  of  illness.  Owing  to  the  continued  pain  it  was  decided  to  relieve  the  intra- 
cranial pressure  by  lumbar  puncture.  I  aspirated  45  cubic  centimeters  of  clear  spinal 
fluid,  which  was  sent  to  Dr.  Billings,  of  the  New  York  Health  Department,  for 
examination.  He  reported  the  presence  of  the  tubercle  bacillus  and  the  diplococcus. 
Dr.  B.  Sachs  confirmed  the  diagnosis  of  tubercular  meningitis. 

Strabismus  was  also  present.  Tliere  was  marked  facial  paralysis.  Nausea  and 
vomiting  occurred.  There  were  spasms  and  tmtchings,  also  a  hsemiple^ic  paralysis. 
There  was  also  a  unilateral  flush  on  the  cheek  and  other  well-marked  evidences  of 
vasomotor  disturbances.  The  child  was  either  soporose,  in  a  semi-stupor,  or  crying 
and  screaming  with  pain  in  the  head.  A  distinct  red  streak  remained  when  the  skin 
was  stroked  with  the  finger  nail,  the  so-called  tache  cerebrale.  The  Babinski  reflex 
was  also  present.  There  was  spastic  rigidity  of  the  entire  body.  The  eyes  were 
half  open.  Respiration  was  labored,  at  times — Cheyne-Stokes  respiration.  The 
pulse  was  small  and  compressible  and  varied  between  80  and  160.  The  child  died  of 
extreme  exhaustion  and  inanition,  after  suffering  about  ten  days  of.  terrible  agony. 


782 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Symptoms  and  Diagnosis. — An  irregular  and  intermitting  pulse  with 
Clie}aie-Stokes  respiration  and  slight  elevation  of  temperature  are  amongst 
the  early  sjinptoms  of  this  disease.  The  pupils  show  irregularity;  not  in- 
frequently one  pupil  will  be  dilated,  while  the  other  may  be  a  pin-point. 


Fig.    262. — Case  of  Tuberculous  Meningitis,  well  marked, 
ending  fatally.      (Original.) 

Vomiting  is  an  early  s}Tnptom  in  many  cases,  and  may  continue  in  spite  of 
rigid  supervision  of  the  diet,  so  that  an  organic  lesion  will  be  suspected. 
The  vomiting  is  usually  projectile  in  character.  Later  in  the  disease,  the 
temperature  ranges  from  100°  to  103°  or  even  higher.     The  pulse  may 


TUBERCULAR  MENINGITIS.  783 

vary  between  80  and  160  beats  per  minute.    The  respirations  are  increased 
and  irregular  in  character,  labored  or  sighing. 

Tache  Gerebrale. — ^The  tache  cerebrale  is  frequently  present.  This  is 
produced  by  drawing  the  finger-nail  quickly  over  the  skin  of  the  abdomen, 
arm,  or  leg,  when  a  sharp,  bright  mark  remains  for  several  minutes. 

Some  symptoms  come  on  very  slowly.  Intense  headache  is  complained 
of  and  is  usually  supra-orbital  in  character.  In  the  case  referred  to  in  this 
chapter  the  symptoms  were  masked  for  a  number  of  days.  The  eyes  usually 
show  tubercles  in  the  choroid.  In  the  case  reported  here,  although  the  eyes 
were  examined  by  two  competent  oculists,  no  evidence  of  disease  could  be 
found.  Strabismus  as  well  as  facial  paralysis  are  frequently  seen  as  evi- 
dence of  paralysis.    Twitchings  are  frequently  noticed. 

The  BabinsJci  reflex  is  very  often  present. 

The  child  sleeps  with  its  eyes  half  open.  There  is  marked  evidence 
of  vasomotor  disturbance,  such  as  unilateral  flushes,  and  spastic  rigidity  of 
the  entire  body  is  repeatedly  seen. 

Lumbar  puncture  will  usually  show  a  clear  cerebro-spinal  fluid.  In 
this  fluid  the  tubercle  bacilli  can  be  located.  In  some  cases  other  pathogenic 
bacteria — for  example,  the  streptococcus — can  be  found. 

Inoculation  of  skin  with  tuberculin — von  Pirquet  test — is  helpful  in 
making  the  diagnosis. 

The  prognosis  is  bad.  I  do  not  know  of  a  single  case  of  distinct  tuber- 
cular meningitis  that  finally  recovered. 

Treatment. — Lumbar  puncture  should  in  all  cases  be  performed.  For 
details  regarding  technique  of  lumbar  puncture  see  chapter  on  "Epidemic 
Cerebro-spinal  Meningitis."  Tapping  the  fourth  or  fifth  ventricle  will 
certainly  relieve  intra-cranial  pressure.  No  more  than  15  to  25  cubic  cen- 
timeters should  be  withdrawn  at  one  aspiration.  I  look  upon  this  as  a  very 
valuable  diagnostic  as  well  as  therapeutic  measure.  The  head  should  be 
shaved,  and  an  ice-bag  or  ice-coil  applied  continuously.  Next  in  impor- 
tance several  leeches  should  be  applied  behind  the  ears,  over  the  mastoid 
process  of  the  temporal  bone.  Cerebral  engorgement  can  also  be  relieved  by 
applying  leeches  to  the  ala)  nasi;  this  will  drain  the  blood  through  the 
frontal  sinus.    Eectal  medication  should  be  remembered. 

Large  doses  (5  to  10  grains)  of  sodium  bromide  and  sodium  iodide 
should  be  given  until  quiet  is  insured.  The  bowels  sliould  be  cleansed  by 
a  thorough  irrigation  with  glycerine  and  water.  Iodoform  collodion  (10 
per  cent.)  can  be  applied  to  the  scalp,  thoroughly,  once  or  twice. 

Inunctions  with  uugiientum  Crede  or  mercurial  ointment,  at  the  nape 
of  the  neck,  rubbed  into  the  lymphatics,  for  at  least  twenty  minutes  several 
times  a  day,  will  frequently  do  some  good. 

Peptonized  milk,  whey,  soups,  broths,  zoolak,  and  buttermilk  are  indi- 
cated.    Under  no  conditions  should  solid  food  be  administered.     If  the 


784  DISEASES  OF  THE  NERVOUS  SYSTEM. 

child  is  in  a  coma^  rectal  feeding  must  be  resorted  to.      (For  details  see 
chapter  on  "Eectal  Feeding.") 

Ceeebeo-spii^al  Meningitis  (Acute  Mexixgitis,  Spotted  Fevee^  oe 
Maligxaxt  Pukpueic  Fever). 

Cerebro-spinal  meningitis  is  an  acute  infectious  disease  characterized 
by  a  sudden  onset  of  s3'mptoms. 

Bacteriology  and  Etiology. — The  presence  of  the  dijDlococcus  intra- 
cellularis  of  Weichselbaum  is  usually  the  causative  agent  of  this  disease.  In 
a  few  cases,  streptococci;  in  others,  pneumococci  have  been  found. 

Weichselbaum  states  that  he  believes  the  meningococcus  is  frequently 
present  and  lies  dormant  in  the  crypts  of  the  tonsils  and  pharynx.  For 
this  reason  he  believes  that,  wlien  a  lowered  vitality  exists  due  to  subnormal 
conditions,  then  the  meningococcus  gains  access  through  the  h'mph  channels 
to  the  meninges  and  sets  up  an  acute  and  sudden  infection.  In  addition 
to  the  presence  of  the  meningococcus  in  the  tonsils,  this  pathogenic  microbe 
is  frequently  found  in  the  nose  from  whence  it  probably  gains  access  through 
the  frontal  sinuses  and  reaches  the  brain.  The  meningococcus  can  be  trans- 
mitted and  an  infection  disseminated  by  direct  contact  with  infected  secre- 
tions containing  the  diplococcus  intracellularis.  Weichselbaum  does  not 
believe  that  the  sudden  appearance  of  a  case  of  cerebro-spinal  meningitis, 
in  an  otherwise  healthy  locality,  is  extraordinar}!-  when  the  etiological  con- 
ditions, such  as  the  possibility  of  harboring  this  diplococcus  in  the  nose  and 
throat,  are  remembered. 

Pathology. — In  the  early  stage  of  this  disease  we  note  h}^erEemic 
conditions  in  the  brain  and  spinal  cord.  When  the  disease  has  progressed, 
the  arachnoid  appears  cloudy,  especially  along  the  course  of  the  blood- 
vessels from  which  a  purulent  exudate  oozes.  This  purulent  exudate  in- 
volves all  the  tissues  of  the  convexity  and  frequently  extends  to  the  base  in 
the  meshes  of  the  pia  and  between  it  and  the  cortex.  The  fluid  in  the 
ventricles  is  as  a  rule  increased,  and  may  contain  small  flocculi  of  fibrin. 
Haemorrhage  is  frequently  noted  in  this  region.  The  joints  show  evidences 
of  septic  inflammation.  The  spleen  is  frequently  enlarged.  Evidences  of 
infection  and  sepsis  are  present  in  all  parts  of  the  intestinal  organs  of  the 
body.  Multiple  abscesses  may  occur,  and  not  infrequently  parenchymatous 
degenerations  involve  the  kidneys,  liver,  and  spleen. 

Purpuric  spots  of  mottling,  so  frequently  seen  on  the  outside  of  the 
body,  may  sometimes  be  seen  more  distinctly  in  the  internal  organs. 

Climatic  Conditions. — The  greatest  number  of  cases  occur  during  the 
winter  months,  while  sporadic  cases  are  seen  in  the  spring,  summer,  and  fall 
months. 


PLATE  xxxvTrr 


«^ 


.^ 


41^ 


«l 


f^ 


^ 


1J 


**^#; 
^c* 


1^ 


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:Mciiingococci  in  Pus-cells,  Spinal  Fluid.     Characteristic  Intracellular 
Arrangement. 


CEREBROSPINAL  MENINGITIS. 


785 


Table  No.  77. — Deaths  from  Ccrebro-Flpinal  Meningiiifi  in  Children  under 
15  years.     'New  York   City— 1902-1907. 


Year. 

Old  New  York  City. 

Greater  New  York  City. 

1002 

156 

221 

1903. 

168 

225 

1904 

806 

1056 

1905 

2775 

1906 

1032 

1907 

828 

Symptoms. — During  the  epidemic  there  were  three  classes  of  cases 
encountered:  first,  a  mild  type;  second,  a  severe  type;  and  third,  an 
abortive  type. 

Mild  Type. — In  this  class  of  cases  there  is  a  slight  rise  of  temperature, 
generally  malaise,  and  perhaps  vomiting. 

Abortive  Type. — This  type  is  usually  seen  in  strong  children  who  are 
able  to  withstand  a  severe  infection.  By  reason  of  their  health  they  are 
infected  in  a  lesser  degree,  as  shown  by  their  symptoms  and  the  rapidity  of 
their  convalescence.  The  onset  is  usually  sudden,  and  I  have  seen  meningeal 
symptoms  subside  within  ten  days  with  no  sequelae.  This  happened  in  a 
case  of  a  child  with  undoubted  cerebrospinal  meningitis,  in  which  the 
diagnosis  was  confirmed  by  the  bacteriological  examination  of  the  spinal 
fluid.  Rhinitis  with  catarrhal  discharge  from  the  nose  is  sometimes  an 
early  symptom  in  this  disease.  Ehinitis  is  frequently  found  in  the  abortive 
type  of  the  disease.  The  danger  of  having  the  meningococcus  in  the  nose 
consists  in  the  ease  with  which  this  pathogenic  bacterium  can  enter  the 
frontal  sinus  and  thus  give  rise  to  encephalitis.  In  the  abortive  type  of  this 
disease  there  frequently  is  a  nasal  discharge  in  which  the  meningococcus 
intracellular  is  can  be  found  long  after  the  rhinitis  has  disappeared.  The 
ambulatory  cases  are  the  ones  which  disseminate  this  infection  because  they 
carry  the  pathogenic  bacteria  from  house  to  house. 

Severe  Type. — In  the  severe  type  there  is  a  sudden  onset  of  symptoms. 
In  older  children  a  distinct  chili  is  usually  the  first  symptom  noted.  The 
skin  feels  hot.  The  temperature  rises  anywhere  between  10'2-105°  F.  (38.8 
and  40.6°  C),  in  the  rectum.  The  pulse  varies;  it  may  be  slow  or  very 
rapid.  The  respiration  is  irregular  in  character,  sometimes  sighing,  and 
labored,  but  most  frequently  Cheyne-Stokes  in  character.  Later  on  there  is 
vomiting,  pain  in  the  head,  in  the  frontal  or  occipital  regions,  and  pain  at 
the  back  of  the  neck.  There  is  moaning  and  frequently  delirium.  Vaso- 
motor disturbances,  such  as  the  flushing  of  one  ear  or  one  cheek,   are 


50 


786  DISEASES  OF  THE  NERVOUS  SYSTEM. 

occasionally  seen.  The  tache  cerebrate  is  usually  noted  when  stroking  the 
breast  with  the  finger  nail,  as  a  distinct  hypersemia  follows  and  remains  for 
several  minutes.  The  tendons  are  very  sensitive  to  the  slightest  pressure. 
The  patellar  reflexes  are  usually  absent.  When  the  thigh  is  flexed  on  the 
abdomen  and  we  try  to  extend  the  leg  there  is  considerable  latent  contraction, 
the  so-called  Kernig  sign.  This  symptom  alone  should  not  be  depended 
upon.  Hyperextension  of  the  big  toe  produced  by  stroking  the  sole  of  the 
foot,  the  so-called  Babinski  reflex,  is  not  always  present.  It  is  also  fre- 
quently noted  in  perfectly  healthy  children.  In  a  series  of  fifty  children 
examined  by  me,  the  Babinski  reflex  was  found  in  forty. 

Brudzinski's  neck  sign  in  tuberculous  and  other  types  of  meningitis  is 
present  in  100  per  cent,  of  those  ill  with  either  cerebrospinal  meningitis, 
serous  or  pneumococcous  meningitis. 

Technique  to  Elicit  NecJc  Sign. — The  head  is  forcibly  flexed  with  the 
left  hand  while  the  child  is  lying  flat  on  its  back;  with  the  right  hand, 
pressure  is  exerted  on  the  chest  to  keep  the  child  from  being  lifted.  If  the 
sign  is  positive,  both  legs  will  flex  on  the  thighs  and  the  thighs  on  the 
abdomen. 

The  identical  collateral  sign  consists  in  flexing  the  leg  on  the  thigh 
and  the  thigh  on  the  abdomen,  when  the  opposite  lower  member  will  assume 
the  same  position. 

The  normal  cytology  of  the  cerebrospinal  fluid  varies  from  0  to  about 
7  lymphocytes  per  cubic  millimeter.  In  any  meningeal  irritation,  acute  or 
chronic,  the  lymphocytes  increase  in  number.  They  may  be  increased  in- 
definitely up  to  thousands. 

In  a  number  of  cerebrospinal  fluids  from  infants,  examined  by  Kaplan, 
he  found  that  in  the  tubercular  forms  the  lymphocytes  predominate.  In 
the  other  acute  meningitides  of  children  the  polynuclears  and  lymphocytes 
claim  about  equal  or  nearly  equal  relations.  It  is  marvelous  how  readily 
the  polynuclears  diminish  if  the  case  shows  the  slightest  tendency  to 
improve,  and,  vice  versa,  they  increase  as  the  inflammatory  process  grows 
worse.  Pari  passu  with  the  polynuclear  increase  the  Fehling  reaction 
disappears.  This  point  is  extremely  important,  as  there  are  a  number  of 
cases  of  tubercular  meningitis  where  the  tubercle  bacillus  cannot  be  found 
even  if  the  antiformin  or  the  Jousset  method  is  used.  In  these  instances 
I  consider  the  copper-reducing  substance  in  the  cerebrospinal  fluid  as  highly 
suggestive  of  the  tubercular  nature  of  the  meningitis.  The  non-reduction 
of  the  Fehling  solution  or  the  appearance  of  a  violet  color  change  instead, 
in  Kaplan's  opinion,  is  significant  of  the  non-tubercular  nature  of  the 
affection  unless  a  mixed  infection  is  at  hand.  In  case  a  double  infection  is 
demonstrated  microscopically,  the  invader  that  has  the  upper  hand  in  the 
infection  usually  reflects  upon  the  behavior  of  the  cerebrospinal  fluid  with 
the  Fehling  solution.     If  it  is  the  tubercle  bacillus  it  will  reduce;  if  it  is 


PLATK   XXXrX 


Cerebrospinal  IMeningitis.  Autopsy  showed  a  ycllowisli-green.  muco- 
purulent exudate,  cheesy  in  character,  covering  the  anterior  two-thirds 
of  the  cerebrum.  Tiie  fluid  obtained  by  lumbar  puncture  as  well  as  that 
by  intraventricular  aspiration  sliowed  a  p\ire  inlluenza  bacillus.  The 
autopsy  was  performed  by  Dr.  John  Larkin,  The  fluid  examined  by  Dr. 
Sophian  and  Dr.  ISI.  D,  Kaplan. 


CEREBRO-SPINAL  MENINGITIS.  787 

another  ofganism  it  will  not.  The  latter  phenomenon  is  due  to  the  fact  that 
it  produces  a  marked  increase  in  the  polynuclears,  which  in  some  way  are 
responsible  for  the  non-reduction.  The  importance  of  cerebro-spinal  fluid 
examinations  in  paediatrics  needs  no  emphasis. 

Either  constipation  or  diarrhoea  may  be  present.  The  bladder  acts 
well,  although  enuresis  may  exist.  In  some  cases  there  is  a  marked  retention 
of  urine.  The  joints  are  usually  swollen,  simulating  rheumatism.  There 
is  also  a  distinct  petechial  eruption  in  some  cases.  Out  of  a  series  of  twenty- 
two  eases  seen  by  me,  six  had  distinct  petechia.  In  six  others  the  skin  had  a 
distinct  eruption  resembling  scarlet  fever.  Owing  to  the  spots  present  in 
this  condition,  the  disease  was  frequently  tenned  "spotted  fever."  The 
pupils  are  usually  dilated;  they  are  sometimes  irregular.  I  have  seen  cases 
during  the  epidemic  of  1905  in  which  one  pupil  showed  marked  dilatation, 
while  the  other  pupil  was  contracted  to  almost  a  pinpoint.  Strabismus  is  a 
frequent  symptom.  Occasionally  we  note  nystagmus.  Photophobia  is  a 
frequent  symptom.  In  one  of  my  cases  the  child  cried  whenever  a  lighted 
candle  was  brought  near  the  eyes.  Opisthotonos  is  usually  present.  The 
severe  rigidity  of  the  sternocleidomastoid  muscle  in  addition  to  the  marked 
rigidity  of  the  arms  and  legs  forms  a  very  prominent  symptom  during  the 
course  of  the  disease.  ,  Owing  to  these  severe  contractures  we  usually  note 
constant  moaning,  most  likely  induced  by  the  pain  caused  by  the  said 
contractures. 

Diagnosis. — A  positive  diagnosis  of  this  disease  can  be  made  by  examin- 
ing tbe  fluid  drawn  by  lumbar  puncture.  As  a  rule  the  spinal  fluid  is  turbid 
or  opaque.  We  do  not  find  the  spinal  fluid  clear  and  transparent,  as  it  is 
seen  in  tuberculous  meningitis.  The  presence  of  the  characteristic  diplo- 
coccus  intracellularis  described  by  Weichselbaum  is  usually  noted.  In  rare 
cases  the  streptococcus  and  the  pneumococcus  have  been  found,  but  these 
latter  are  the  exception.  The  bacteriological  diagnosis,  according  to  Weich- 
selbaum, depends  on  the  diplococcus  being  Gram  negative,  or  decolorized  by 
Gram.  It  is  important  to  remember  that  the  Micrococcus  caiarvhalis  is  fre- 
quently found  in  the  nasal  passage;  hence,  great  care  must  be  exercised  to 
differentiate  the  same,  both  in  its  relation  to  Gram  staining  and  also  in  its 
morphological  characters. 

The  following  two  cases  will  serve  to  illustrate  the  method  of 
treatment : — 

Case  I. — Emilio  Gr.,  four  months  old,  was  admitted  to  the  Sydenliam  Hospital, 
January  6,  1909.     Family  history  negative. 

Personal  History. — Normal  delivery.     Full  term.     Bottle-fed  since  birth. 

Present  illness  began  two  weeks  ago  with  twitehings  of  the  muscles.  One 
week  ago  mother  noticed  retraction  of  the  head.  There  had  been  no  vomiting.  The 
baby  had  moaned  almost  constantly. 

Physical  Examination. — ^Head  showed  bald  occiput.  The  anterior  fontanel  was 
open  and  slightly  bulging.     The  pupils  were  equal   and  slightly  contracted.     There 


788  DISEASES  OP  THE  NERVOUS  SYSTEM. 

was  marked  retraction  of  the  head,  amounting  to  opisthotonos.  The  chest  showed 
poor  expansion.  There  was  a  systolic  murmur  heard  at  the  apex  of  the  heart.  The 
lungs  over  left  base,  posteriorly,  showed  small  areas  of  dullness,  bronchial  voice, 
and  breathing.  The  abdomen  was  retracted.  The  liver  and  spleen  were  not 
palpable.  There  was  marked  rigidity  of  both  arms  and  legs.  The  reflexes  were 
exaggerated.  Kernig's  sign  was  not  elicited.  Lumbar  puncture  showed  turbid  fluid 
in  which  the  Diplococcus  intracellularis  was  found. 

The  duration  of  the  disease  was  thirty-six  days.  By  means  of  ten  lumbar 
punctures,  I  aspirated  146  cubic  centimeters  spinal  fluid,  and  in  nine  intraspinal 
injections,  I  injected  245  cubic  centimeters  Flexner  serum.  The  average  injection 
was  about  30  cubic  centimeters.  The  child  made  a  complete  recovery  without  any 
sequelae. 

Case  II. — Intraventricular  Method  of  Serum  Injection. — Dora  B,.,^  two  months 
old,  was  admitted  to  the  Babies'  Ward  of  the  Sydenham  Hospital,  October  2,  1909 ; 
she  was  a  well-nourished,  breast-fed  infant,  having  had  no  previous  illness.  There 
was  a  sudden  onset  with  vomiting,  loss  of  appetite,  rigidity  of  head,  neck,  and  extremi- 
ties, rolling  of  the  eyeballs,  insomnia,  and  convulsive  movements.  The  anterior  fon- 
tanel was  open  one-half  inch  in  diameter,  and  slightly  bulging.  The  posterior  fon- 
tanel was  almost  closed;  The  pupils  were  equal,  and  reacted  sluggishly  to  accom- 
modation and  light. 

The  thorax,  ears,  and  throat  were  excluded  as  a  possible  source  of  disease. 

On  the  fifth  day  after  admission,  and  on  two  succeeding  days,  lumbar  puncture 
was  performed  resulting  in  dry  tap.  With  the  three  successive  dry  taps,  the  symp- 
toms of  rigidity,  opisthotonus,   fever,   and  twitching  increased. 

On  October  20th,  I  decided  to  tap  the  lateral  ventricles  by  entering  the  ante- 
rior fontanel  at  the  right  angle.^  The  aspiration  needle,  about  8  centimeters  in 
length,  was  introduced  downward  and  toward  the  median  line,  at  an  angle  of  about 
20  degrees,  to  a  depth  of  about  4.3  centimeters,  the  needle  entering  the  lateral 
ventricles  near  the  median  line.  About  15  cubic  centimeters  of  turbid  purulent  fluid 
were  withdrawn,  which  was  identified  at  the  Rockefeller  Institute  as  a  meningo- 
coccus intracellularis.  The  ventricles  were  then  irrigated  with  normal  saline  solu- 
tion, at  body  temperature.  The  excess  fiuid  was  allowed  to  drain  out  through  the 
needle,  and  25  cubic  centimeters  of  Flexner  anti-meningitis  serum  were  slowly 
injected  into  the  ventricles.  During  the  injection  of  the  serum  the  infant  changed 
in  color  from  a  waxy  pallor  to  a  uniform  red  fiush  all  over  the  body.  One-half  hour 
after  the  injection  of  the  serum  the  infant  still  remained  flushed,  perspired  profusely, 
and  had  some  frothing  at  the  mouth.  Otherwise  the  general  condition  was  good. 
The  temperature  was  98°  F.;  respiration,  80,  and  pulse,  120. 

On  October  21st,  the  ventricles  were  again  irrigated  with  40  cubic  centimeters 
of  normal  saline  solution,  and  20  cubic  centimeters  of  serum  were  injected. 

October  24th,  the  child's  general  condition  was  very  poor.  Opisthotonos  was 
marked.  The  body  rigidly  bent  in  the  form  of  a  bow.  The  arms  were  rigidly 
extended  and  the  palms  everted  outward. 

October  25th,  and  during  the  following  week,  daily  injections  of  30-50  cubic 
centimeters  of  serum  were  injected  either  into  the  ventricles  or,  on  two  days,  into 
the  spinal  canal  and  lateral  ventricles.  The  total  amount  of  Flexner  serum  injected 
was  180  cubic  centimeters;  the  total  amount  retained  in  the  ventricles  and  spinal 
canal  was  about  100  cubic  centimeters.     The  child  made  a  complete  recovery. 

^  This  case  was  presented  at  the   Section   on   Pediatrics,   New  York  Academy 
of  Medicine,  March  10,  1910, 
*  See  Plate  XLI. 


IM.A'I'K   XI. 


Cerebrospiiial  Mciiiiicfitis  due  to  the  Tnfliu'iiza  llaeilhis.  A,  A.  Anterior 
oorcbvum  covered  witli  a  thick  iiiiico-purulent  exudate.  B,  H.  Normal 
eerchnini.  C.  Sujx-rior  lonjiitiidinal  siiui?;.  D.  Reltceted  iiiteguiuejits. 
I<j.  Frontal  siims.  This  infci'lion  has  been  seen  hy  me  in  an  infant  t  iiiDiitlis 
old.  Tlie  infeet'on  |irohal)!y  enters  tlirougli  the  IvTnpli  cliannels  in  the  naso- 
])haryn\,  tluis  reaehing  tlie  base  of  tlie  brain.  The  bacillus  may  also  liave 
entered  tluough  the  frontal  sinus.  In  the  spinal  fluid  as  well  as  in  the 
venlriciilai-  llnid  a  ]iure  cullufe  of  tlie  influenza  bacillus  was  fount!.  The 
infant  died  t)f  convulsions.  The  autdjjsy  performed  by  Dr.  John  i-arkin 
showed  the  anterior  two-i birds  of  tlie  ccrc])rum  was  cov(M'('d  with  a  thick, 
mueo-2)urulent,  greenish  exudate,  clu-esy  in  cliaracter.  Tlie  convolutions 
of  the  cerebrum  were  obliterated  and  coxcrcd  by  a  thick  exudate,  the 
surface  of  which  \vas  marked  by  many  whitisli  nodules  and  a  number  of 
pits  near  the  falx  cerebri.  At  tlic  frontal  lobe  of  brain  <m  riglit  sidt^ 
a  (larl<,  necrotic  area  was  seen.  Illustr;it  ion  shows  the  caharium  remo\ed. 
tlie  dura  mater  incised  longitudinnllx-  on  either  side  of  the  superior  lon- 
gitudinal  siiHises  iind  retlected  laterally,  exposing  the  entire  cerebrum. 


CEREBROSPINAL  MENINGITIS. 


789 


The  symptoms  are  gradually  subsiding,  tlio  rigidity  is  lessened,  hut  on  being 
handled  opisthotonus  is  very  evident. 

November  29th.  No  decided  change,  but  infant  improving  slowly.  The  lateral 
ventricles  Avcre  aspirated  and  50  cubic  centimeters  of  clear  fluid  wliicli  did  not  con- 
tain the  meningococcus 
withdrawn. 

December  fith.  In- 
fant was  "  discharged 
cured.  No  complication 
of  eyes  and  ears  existed. 

It  is  now  two  months 
since  this  infant  was  dis- 
charged, she  has  since  de- 
A^eloped  a  tooth,  sleeps 
well,  nurses  well,  and  is 
a  happy  healthy  infant. 

Lumbar  Puncture,  i 

—  The  subarachnoid 
space  is  frequently  tap- 
ped for  diagnostic  and 
therapeutic  purposes. 
Either  space  between 
the  third  and  fourth, 
or  the  fourth  and  fifth, 
lumbar  vertebra  may 
be  chosen.  The  child 
is  placed  on  either  side 
with  the  spinal  curve 
toward  the  operator, 
in  this  way  spreading 
the  vertebra  so  that 
the  greater  angle  formed  by  the  vertebree  is  toward  the  operator.  An 
imaginary  line  drawn  through  the  crest  of  the  ilium  to  the  spine  is  an  easy 
means  of  locating  the  place  to  puncture. 

Kind  of  Needle  Required. — In  making  a  lumbar  puncture  we  should 
use  such  a  needle  as  would  be  required  in  making  a  puncture  for  empyema. 


Fig.  263.' — Anatomical  Illustration  Showing  the  Place 
Best  Adapted  for  Lumbar  Puncture.  The  needle  should 
be  inserted  in  the  lumbar  space  shown  by  the  cross. 
(Original.) 


Fig.    264.- — Lumbar   Puncture  Needle. 


The  needle  should  be  pushed  a  little  upward  and  forward  until  it  enters  the 
spinal  canal,  then  the  stylet  should  be  withdrawn.  If  the  fluid  does  not 
escape  through  the  needle,  then  withdraw  it  slightly  and  reintroduce  the 
stylet  to  dislodge  any  obstruction  in  the  caliber  of  the  needle.     Make  the 


1  First  described  by  Quincke. 


790 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


puncture  as  simple  as  possible  rather  than  lacerate  the  tissue  around  the 
vertebral  column  and  cause  bleeding  by  lateral  movements  of  the  needle. 

Amount  of  Fluid  to  he  Withdrawn. — For  diagnostic  purposes  15  to  20 
cubic  centimeters  should  be  withdrawn,  if  the  fluid  is  watery  and  clear.  If 
the  spinal  fluid  is  turbid,  then  the  more  we  can  withdraw,  the  better.  I  have 
withdrawn  as  much  as  50  to  60  cubic  centimeters.  If  the  diploco.ccus  intra- 
cellularis  is  found  in  the  spinal  fluid,  it  is  especially  important  to  with- 
draw as  much  of  the  fluid  as  possible. 

The  site  of  puncture  should  be  closed  with  a  strip  of  adhesive  plaster. 


Fig.    265. — Lumbar  Puncture  Made  Between  Fourth  and  Fifth 
Lumbar  Vertebrae. 

Local  Anwsthesia. — Ethyl  chloride  in  the  form  of  a  spray  is  useful  in 
very  sensitive  children.  It  is  not  necessary  to  have  general  angesthesia 
during  this  procedure.  General  rules  of  asepsis  must  be  strictly  applied  to 
the  child's  skin,  the  operator's  hands,  and  to  the  needle  used. 

Dry  Tap  in  Lumbar  Puncture. — We  may  have  a  dry  tap : — 

1.  If  the  caliber  of  the  needle  is  small,  and  the  spinal  fluid  very  thick. 

2.  If  adhesions  are  present  at  the  base  of  the  brain,  preventing  the 
passage  of  fluid  from  the  ventricles  to  the  subarachnoid  space. 

3.  If  a  successful  puncture  has  been  made,  a  dry  tap  may  follow,  due 
to  inflammatory  adhesions  caused  by  the  previous  introduction  of  the  needle. 

4.  The  closing  of  the  foramen  of  Magendie  is  the  most  frequent  result 
of  the  inflammatory  process,  resulting  in  dry  tap. 

5.  A  fibrin  clot  or  the  presence  of  the  cord  in  front  of  the  needle  may 
prevent  the  outflow  of  the  cerebro-spinal  fluid. 


CEREBRO-SPINAL  MENINGITIS.  79I 

To  be  sure  that  we  are  in  the  spinal  canal,  if  a  dry  tap  exists,  leave 
the  needle  in  situ  and  introduce  a  second  needle  two  spaces  lower.  Sterile 
water  if  injected  through  the  upper  needle  will  flow  out  of  the  lower  needle, 
proving  that  we  are  in  the  spinal  canal. 

The  spinal  cord  in  infants  terminates  about  the  level  of  the  lumbar 
vertebrae.  The  introduction  of  the  needle  is  simplest  between  the  third  and 
fourth,  or  the  fourth  and  fifth,  lumbar  vertebrae.  In  these  interspaces  there 
is  no  cord;  hence  no  injury  can  follow.  An  imaginary  line  drawn  through 
the  crest  of  the  ilium  corresponds  to  the  fourth  intercostal  space. 

Prognosis  and  Sequelae. — Heretofore  the  prognosis  was  always  bad; 
since  the  introduction  of  the  Flexner  serum  a  decided  improvement  has  been 
noted.  Where  formerly  70  to  80  cases  died  and  only  20  to  30  cases 
recovered,  we  now  have  the  reverse,  70  to  80  recoveries  and  only  30  to  30 
deaths.  The  prognosis  is  better  if  the  serum  treatment  is  given  early  in 
the  disease. 

The  duration  of  this  disease  may  be  short  or  very  long.  Young  infants 
have  been  attended  by  me  more  than  two  months  before  recovery  took  place. 
Some  cases  after  serum  treatment  recover  entirely;  others  have  atrophy  of 
the  optic  nerve  resulting  in  blindness.  Deafness  is  a  frequent  and  permanent 
injury  in  some  cases. 

Treatment. — Fever  Treatment. — Antipyretic  measures  such  as  cold 
packs,  ice  bag  on  the  head,  and  tub  baths  are  indicated.  The  coal-tar 
products,  owing  to  their  depressing  effect  upon  the  heart,  should  be  avoided. 
Cupping  of  the  neck  and  spine  sometimes  relieves  internal  congestion. 
Lumbar  puncture  should  be  performed. 

Eliminative  Treatment. — This  consists  in  cleansing  the  gastro-intes- 
tinal  tract  with  the  aid  of  citrate  of  magnesia  or  calomel.  When  high  fever 
exists,  flushing  the  rectum  and  colon  with  a  cold  soap-suds  enema  will  be 
found  useful. 

Medicinal  Treatment. — To  relieve  the  vomiting  cracked  ice  should  be 
given,  in  addition  to  1-grain  doses  of  menthol.  To  relieve  muscular  spasm, 
twitching,  and  delirium,  hyoscine  hydrobromate,  in  doses  of  ^/eoo  to  Vsoo 
grain,  should  be  given  and  repeated  every  few  hours.  Morphine  hypo- 
dermically,  in  doses  of  V50  grain,  gradually  increased,  is  also  valuable. 
Leeches  applied  at  the  nape  of  the  neck,  or  over  the  mastoid  portion  of  the 
temporal  bone,  or  at  the  alse  nasi  will  sometimes  relieve.  Sodium  bromide, 
in  5-  to  30-  grain  doses,  may  be  given  until  the  systemic  effect  is  noted. 
Codeine,  ^/^o  grain  gradually  increased  until  %  grain  is  given,  will  fre- 
quently soothe  the  nervous  system.  The  soothing  effect  of  a  warm  bath  is 
generally  recognized.  The  bath  should  be  given  at  a  temperature  of  100° 
to  105°  F.  in  a  bathtub  of  water  to  which  14  to  %  pound  of  sulphur  has 
been  added.  A  warm  sulphur  bath  may  be  given  twice  a  day.  The  dura- 
tion of  each  bath  should  be  at  least  ten  to  thirty  minutes. 


792  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Meningitis  Serum} — The  specific  value  of  the  anti-meningitis  serum 
has  been  demonstrated  many  times.  In  some  cases  reported  there  has  been 
a  sudden  crisis  and  an  amelioration  of  all  the  sjnnptoms.  My  experience 
has  been  especially  good  in  young  infants  under  one  year.  While  formerly 
all  infants  of  tender  age  died,  we  now  have  a  number  of  cases  reported, 
including  my  own,  in  which  absolute  recovery  has  taken  place. 

Intraspinal  Injections. — By  lumbar  puncture  we  aspirate  as  much  of 
the  spinal  fluid  as  possible;  in  some  cases  15  to  30  cubic  centimeters  were 
obtained.  Through  the  same  needle  left  in  situ  I  inject  from  30  to  60  cubic 
centimeters  of  Flexnei-'s  serimi  by  the  gravity  method.  The  serum  should 
be  warmed  before  injecting,  and  should  be  injected  slowly.  It  is  better  to 
elevate  the  hips  and  lower  the  head  when  injecting  the  serum.  Daily  injec- 
tions of  30  to  60  cubic  centimeters  are  required  if  no  improvement  is  noted. 

Intracranial  Injections.^ — The  scalp  should  be  shaved  and  prepared 
with  the  usual  aseptic  precautions.  The  aspirating  needle  must  be  rendered 
sterile  by  boiling.  It  is  then  pushed  through  the  anterior  fontanel  down- 
ward and  inward  into  the  ventricles  of  the  brain,  at  least  one  inch  or  more. 
The  needle  is  inserted  about  one-fourth  inch  to  one  side  of  the  longitudinal 
sinus. 

Kocher  advocates  puncturing  through  the  frontal  lobe  at  a  point  2^/2 
centimeters  from  the  middle  line  and  3  centimeters  anterior  to  the  central 
fissure — a  point  lying  somewhat  in  front  of  the  bregma.  The  needle  must 
penetrate  4  or  5  centimeters  before  it  reaches  the  ventricles  and  should  be 
directed  somewhat  downward  and  backward. 

The  ventricles  at  this  situation  are  broad,  extending  fully  2  centimeters 
from  the  middle  line,  and  there  is  practically  no  risk  of  haemorrhage  during 
the  passage  of  the  needle.  With  experience  and  after  practice  on  the  cadaver, 
punctures  may  be  safely  made,  not  only  at  the  point  of  Keen  and  Kocher, 
but  elsewhere  if  need  be— through  the  anterior  pole  of  the  frontal  lobe, 
through  the  pole  of  the  occipital  lobe,  etc. ;  but  these  methods  are  more 
hazardous  than  those  detailed  above,  and  should  only  be  undertaken  by 
operators  who  are  particularly  familiar  with  intracranial  work.  In  infected 
cases  with  a  beginning  external  meningitis,  there  is  always  a  certain  risk  of 
inoculating  an  uninfected  ventricle.  The  same  accident  has  occurred  owing 
to  the  passage  of  an  occluded  needle  through  an  abscess  and  then  into  the 
ventricle.  A  trochar  should  not  be  used.  It  is  advisable  to  employ  a  needle 
with  a  sharply  blunt  point,  which  will  pass  by  vessels  without  cutting  them. 


*  I  am  indebted  to  Dr.  Simon  Flexner,  of  the  Rockefeller  Institute,  for  the  anti- 
meningitis  serum  used  in  these  cases. 

*  I  am  indebted  to  my  house  staff,  Dr.  Bobrow,  Dr.  Clurman,  Dr.  Littenberg, 
and  Dr.  Freund,  for  careful  notes  and  records  of  a  series  of  cerebro-spinal  meningitis 
cases  treated  at  the  hospitsJ.    See  clinical  case,  page  788. 


PLA^IK  XLI 


Translucent  Head  of  Child.  The  needle  entering  the  outer  angle  of  the 
anterior  fontanelle,  and  penetrating  the  lateral  ventricle,  which  is  seen  in  shaded 
outline.  The  falx  is  dimly  seen.  The  right  line  running  from  before  back- 
wards is  the  septum  lucidum  dividing  the  two  ventricles.     (Original.) 


CEREBROSPINAL  MENINGITIS.  793 

The  opening  in  the  needle  should  be  on  the  side  and  not  upon  the  point; 
else  they  become  plugged  by  the  brain  matter. 

At  the  Babies'  Wards  of  the  Sydenham  Hospital  we  have  aspirated, 
many  times,  50  cubic  centimeters  of  purulent  liquid  containing  the  diplo- 
coccus  intracellularis  in  almost  a  pure  culture.  By  using  this  same  needle, 
or  one  having  a  larger  caliber,  we  irrigated,  using  a  pint  of  normal  saline 
solution.  After  draining  off  as  much  as  possible,  50  cubic  centimeters  of 
Flexner's  serum  were  injected.  This  plan  of  treatment  was  successfully 
used  in  two  of  my  cases.  In  both  cases  the  lumbar  puncture  yielded  a 
dry  tap. 

The  purulent  discharge  gradually  lessened  and  the  meningococci  grad- 
ually disappeared  after  continued  serum  injections  extending  over  a  period 
of  four  weeks.  It  was  possible  to  aspirate  and  draw  off  between  50  and  60 
cubic  centimeters  of  a  clear,  transparent  hydrocephalic  fluid  containing  no 
germs. 

A  decided  reaction  followed  each  and  every  injection  of  serum.  During 
the  injection  of  serum,  the  child  changed  in  color  from  a  waxy  pallor  to  a 
uniform  red  flush  all  over  the  body.  One-half  hour  after  the  injection  of 
the  serum,  the  child  still  remained  flushed  and  perspired  profusely,  and  had 
some  frothy  mucus  at  the  mouth. 

The  pulse-rate  was  increased,  the  volume  improved,  and  the  tension 
much  higher.  The  leucocytes  were  invariably  increased.  The  polynuclear 
leucocytes  were  also  increased  after  each  injection.  As  a  rule  the  mono- 
nuclear leucocytes  and  the  lymphocytes  were  reduced  within  six  hours  after 
the  serum  injection. 

In  the  treatment  of  the  severe  type  of  cerebro-spinal  meningitis,  we 
must  persist  even  though  convulsions  recur.  We  must  afford  relief  by  drain- 
ing the  ventricles  of  as  much  of  the  cerebro-spinal  fluid  as  possible.  This 
must  be  followed  up  by  an  intraspinal  injection  of  sufficient  antimeningitis 
serum,  as  previously  mentioned  in  this  article.  One  of  my  cases  was  saved, 
although  the  prognosis  was  absolutely  fatal,  by  the  persistence  of  the  above- 
outlined  treatment. 

In  an  infant  having  an  open  fantanel  it  is  a  simple  plan  to  aspirate 
the  lateral  ventricle,  and  thus  relieve  the  intracranial  pressure.  I  have  fre- 
quently found  persistent  convulsions  that  would  cease  soon  after  the  ven- 
tricles were  relieved  of  the  intracranial  fluid. 

No  one  should  expect  to  cure  a  case  unless  life  is  sustained  with  suffi- 
cient nutrition.  Food  must  be  given  by  mouth  if  possible.  If  the  jaws  are 
rigid,  due  to  spasm,  we  must  resort  to  rectal  feeding  of  peptonized  milk  or 
peptonized  yolk  of  egg  with  an  equal  quantity  of  starch  water.  The  method 
of  rectal  feeding  consists  in  first  cleansing  the  rectum  and  colon  by  an  in- 
jection of  a  pint  of  soap  water,  and  after  the  parts  are  thoroughly  cleansed, 
injecting  quickly  through  a  long  catheter  into  the  colon  two  or  three  ounces 
of  the  peptonized  food. 


^94  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Feeding. — Unless  the  strength  is  supjDorted  by  food  our  patient  will 
die  of  exhaustion.  Feeding  by  mouth  with  peptonized  milk,  broth,  gruel, 
and  eggs  is  indicated.  If,  however,  there  is  vomiting  and  the  stomach  does 
not  retain  food,  then  rectal  feeding  should  be  resorted  to  at  intervals  of 
three  or  four  hours.  This  method  of  feeding  has  already  been  described 
in  the  chapter  on  "Infant  Feeding/^ 

After  Treatment. — If  the  case  progresses  favorably,  careful  attention 
must  be  given  to  restorative  treatment.  Codliver-oil,  Fowler's  solution, 
iodide  of  sodium,  and  the  hypophosphites  must  not  be  forgotten.  Electricity 
must  not  be  forgotten  combined  with  massage  and  sea-salt  bathing.  They 
are  indicated  during  convalescence.  Milk,  cream,  butter,  eggs  and  cereals 
should  form  the  bulk  of  restorative  nutrition.  A  decided  change  of  air  from 
the  city  to  the  sea-shore  or  to  the  mountains  will  prove  beneficial. 

Acute  Pachymeningitis   (Inflammation  of  the  Duea  Mater). 

This  condition  frequently  follows  middle-ear  disease,  although  it  may 
be  the  result  of  injury  to  the  cranium.  It  is  frequently  associated  with 
inflammation  of  the  pia  mater  (leptomeningitis).  It  is  very  difficult  to 
diagnose.  It  usually  follows  ear  disease  and  the  symptoms  of  meningitis  are 
associated.     The  treatment  is  surgical. 

Chronic  Pachymeningitis. 

Chronic  pachymeningitis  can  be  divided  into  two  forms — ^hemorrhagic 
and  non-hsemorrhagic.  There  may  be  punctate  haemorrhages  or  there  may 
be  very  large  hsemorrhagic  areas.  Some  authors  state  that  this  condition 
is  very  rare.  It  aflects  the  inner  layer  of  the  dura  mater.  It  is  frequently 
called  pseudo-membranous  and  hEemorrhagic,  or  hsematoma  of  the  dura 
mater. 

In  cases  where  life  is  prolonged  for  years,  there  may  be  partial  or  even 
complete  absorption  of  the  clot,  followed  by  the  formation  of  cysts,  con- 
siderable inflammatory  thickening  of  the  pia  with  deposits  of  blood  pigment, 
and  finally  atrophy  and  sclerosis  of  the  cortex.  The  source  of  the  haemor- 
rhage may  be  the  rupture  of  a  single  large  vessel,  but  more  frequently  the 
blood  comes  from  many  small  vessels. 

Symptoms  and  Diagnosis. — It  is  very  difficult  to  give  positive  symptoms 
by  which  this  condition  can  be  recognized  during  life.  Coma,  convulsions, 
stupor,  and  vomiting  are  the  main  symptoms.  Unilateral  hsemorrhage  causes 
rigidity  affecting  one  arm  and  leg,  but  if  the  haemorrhage  is  diffused  all 
the  extremities  are  affected.  The  pupils  may  be  dilated  or  contracted; 
sometimes  one  pupil  is  dilated  and  the  other  is  contracted.  The  respira- 
tion and  pulse  are  slow  and  irregular.  There  is  usually  fever,  the  tem- 
perature being  as  high  as  105°  or  as  low  as  100°  F. 


CEREBRAL  PARALYSIS.  795 

Opisthotonos  may  be  absent.  The  patellar  reflex  is  usually  exag- 
gerated.    Convulsions  appear  and  death  ends  the  scene. 

The  differential  diagnosis,  according  to  Holt,  is  as  follows:  "Without 
large  haemorrhages,  pacliyniwiingitis  interna  cannot  be  diagnosticated;  and 
it  is  impossible  to  differentiate  the  haemorrhagic  cases  from  other  varieties 
of  meningeal  haemorrhage.  It  is  important  to  make  a  diagnosis  between 
pachymeningitis  with  luiomorrhage,  and  acute  simple  meningitis.  In  the 
former  we  have  a  sudden  onset;  stupor  occurring  early,  usually  on  tl;e 
first  day,  gradually  diminishing  in  cases  of  recovery,  or  deepening  into 
coma  in  fatal  cases;  localized  or  general  paralysis,  also  occurring  early; 
there  is  no  fever  in  the  beginning,  and  only  moderate  fever  at  the  close. 
In  acute  meningitis  we  usually  have  a  higher  temperature,  especially  early 
in  the  disease;  coma  develops  later,  and  rigidity  of  the  extremities  is  less 
pronounced.  In  certain  cases,  however,  where  the  haemorrhage  occurs  in 
the  course  of  some  other  disease,  a  differential  diagnosis  may  be  impossible." 

The  prognosis  is  usually  fatal.  If  small  hajmorrhages  take  place,  the 
paralysis  may  remain  for  years. 

Treatment.  —  The  scalp  should  be  shaved  and  an  ice-bag  applied. 
Leeches  should  be  applied  to  the  mastoid  to  relieve  cerebral  congestion. 
Large  doses  of  bromide  and  ergot  w411  sometimes  do  good.  The  emunc- 
tories  must  be  carefully  watched  and  aided  if  necessary. 

Ceeebeal  Paralysis  (Spastic  Diplegia.      Paraplegia. 
Hemiplegia). 

There  are  two  forms  of  palsy  usually  seen.  AYhen  the  face,  arm,  or 
leg  is  palsied  it  is  called  monoplegia.  When  the  two  lower  extremities  are 
affected,  paraplegia.  AVhen  one  side  is  affected,  hsemiplegia.  When  both 
sides  are  affected,  diplegia. 

They  occur  in  one  of  three  periods :  first,  during  intra-uterine  life 
(prenatal)  ;  second,  traumatism  during  labor;  third,  palsies  after  birth 
of  the  child. 

Etiology. — Injury  to  the  mother  frequently  injures  the  cerebrum  of 
the  foetus.  Toxic  conditions,  especially  those  associated  with  the  infec- 
tious disease  resulting  in  muscular  degeneration,  frequently  cause  palsy. 
Compression  of  the  infantile  brain  and  its  circulation  during  a  slow  labor 
may  produce  thrombosis  or  meningeal  haemorrhage.  This  condition  is  most 
liable  to  occur  in  a  primipara.  Whooping-cough  has  caused  cerebral  haem- 
orrhage and  injury  and  compression  to  the  cortex  ending  in  paralysis. 

Syphilis  may  be  a  frequent  cause  of  this  condition.  Epilepsy  is  found 
in  over  two-thirds  of  all  cases  as  a  sequela. 

Pathology. — Very  interesting  data  are  contributed  by  Peterson  and 
Sachs,  to  whom  I  am  indebted  for  the  following  classification : — 


796 


DISEASES  OF  THE  NERVOUS  SYSTEM. 
Table  No.  78. 


Groups. 


Pathological  Changes. 


I.      Paralyses  of  intra-uterine  onset 


II.     Paralyses     occurring    during 
labor. 


III.   Paralyses  acquired  after  birth. 


Large  Ceeebeal  Defects  (true  porencephaly). 

H^MOKEHAGES  OF  Intea-uteeine   Origin    (soft- 
ening?). 

Agenesis  Coeticalis. 

Meningeal    H^moeehagb   (very  j-eldom  intra- 
cerebral). 
Eesulting      conditions :       meningo-encephalitis 
chronica  ;  sclerosis  ;  cysts  ;   atrophies  (poren- 
cephalies). 

Meningeal  H^moeehage  (very  seldom  intra- 
cerebral) ;  Embolism  ;  Theombosis  (in 
marantic  conditions  and  occasionally  from 
syphilitic  endarteritis ) . 
Results  of  these  vascular  lesions  ;  cysts  ;  soften- 
ing ;  atrophy  ;  sclerosis  (diiiuse  and  lobar). 

Cheonic  Meningitis. 

Hydeocephalus  (seldom  the  sole  cause). 

Peimaey  Encephalitis  (Strtimpell)  (?). 


"A  summary  of  the  pathological  lesions  resulting  from  acute  ap- 
oplexies consists  of  atrophies,  sclerosis,  and  other  changes  due  to  haemor- 
rhage; also,  embolism  and  thrombosis." 

"Fatty  degeneration  of  the  blood-vessels  is  the  probable  explanation 
of  the  escape  of  blood  in  a  large  number  of  cases."  Heart  lesions,  pneu- 
monia, and  other  infectious  diseases  predispose  to  embolism. 

The  secondary  changes  result  in  sclerosis  or  areas  of  softening.  "The 
sclerosis  is  largely  responsible  for  the  imbecility  and  epilepsy;  transverse 
fibers  connecting  intimately  all  parts  of  the  hemispheres." 

Spencer  studied  130  cases  of  still-bom  children.  He  found  53  cases 
due  to  haemorrhage  from  the  pia  and  arachnoid.  In  29  cases  there  was 
bilateral  haemorrhage,  10  in  the  left  side  only;  10  in  the  right  side;  7 
in  the  lateral  ventricles;  6  at  the  base  of  the  brain;  1  case  of  intra-cere- 
bral  haemorrhage;  4  cases  of  thrombosis  of  the  longitudinal  sinus. 

The  following  case  occurred  in  the  practice  of  Dr.  A.  C.  Cotton,  of 
Chicago : — 

Edith  N.,  age  10  years,  oldest  in  family  of  four  children.  Others  normal. 
Mother  not  in  good  health  during  gestation.  Labor  lasted  twelve  hours.  No 
forceps.  Child  was  always  irritable,  but  had  no  convulsions  until  four  months  of 
age,  when  first  tooth  appeared.  There  were  frequent  recurrences  of  spasms,  two  to 
four  daily.  Has  never  walked,  stood  alone,  nor  been  able  to  support  her  head.  The 
circumference  of  the  head  .was  nineteen  inches. 


CKllEBllAL  PARALYSIS. 


797 


Present  Condition. — Tlie  .skin  i.s  cool,  with  a  tendency  to  cyanosia.  The  body 
is  emaciated;    tliere  is  a  flaring  of  the  ribs,  and  the  sploen  sliows  a  distinct  scoliosis. 

The  mouth  is  open  so  tiiat  tli«  saliva  constantly  dribbles.  The  jaws  are  de- 
formed and  the  face  presents  a  starched  appearance.  There  are  contractures  and 
spasticity  in  both  upper  and  lower  extremities.  The  reflexes  are  exaggerated.  In- 
telligence nil. 

Symptoms  and  Diagnosis. — The  following  symptoms  are  common  to  all 
forms  of  palsy :  Rigidity  of  the  muscles,  contraction  of  tendons,  and  exagger- 


Fig.    266. — Infantile  Cerebral  Paralysis.     (Kindness  of  Dr.  A.  C.  Cotton.) 


ation  of  all  the  deep  reflexes.  Convulsions  and  coma  commonly  jn-ecede  the 
diseased  state.  Most  cases  of  diplegia  and  paraplegia  are  congenital,  wliile 
most  cases  of  ha3miplegia  are  acquired  after  birth. 

Palsies  nsually  follow  a  difficult  labor.  Strabismus  and  facial  paralysis 
are  frequently  noticed.  Aphasia  may  be  present  in  children  that  had 
previously  learned  to  talk.  The  reflexes  on  the  affected  side,  knee  and 
elbow,  are  usually  exaggerated  (Peterson,  Taylor,  and  Wells). 

When  athetosis  is  found,  it  is  usually  associated  with  imbecility  and 
idiocy. 

In  associated  movements  the  exact  imitation  of  the  paralyzed  hand 


1^98  DISEASES  Of  the  Nervous  system. 

and  fingers  of  voluntary  movements  made  hy  the  normal  hand  and  fingers 
takes  place.  Choreiform  movements;,  called  by  Weir  Mitchell  post-paralytic 
chorea,  are  frequently  mistaken  for  chorea.  Peterson^  describes  two  con- 
genital hsemiplegias — a  hitherto  unnoted  morbid  movement  to  which  he  has 
given  the  name  post-hcemiplegic  polymyoclonus.  The  movements  are  neither 
choreiform  nor  athetoid,  but  are  constant  clonic  contractions  of  most  of  the 
muscles  in  the  limbs  affected,  not  occurring  synchronously,  and  the  rhythm 
being  about  that  of  paralysis  agitans  (five  per  second).  All  of  these  move- 
ments indicate  interference  with  motor  conduction  due  to  lesions  in  some 
part  of  the  voluntary  and  inhibitory  tracts. 

The  following  schedule  of  symptoms  by  Jacobi  is  useful  in  showing  the 
diagnostic  features  of  the  different  palsies: — 

Upper  Extremity. — Deltoid:  Absence  of  deformity,  which  is  averted 
by  weight  of  arm.  Inability  to  raise  arm.  Sometimes  subluxation.  Fre- 
quent association  with  paralysis  of  biceps,  brachialis  anticus,  and  supinator 
longus. 

Lower  Extremity. — Ilio-psoas :  Bare  except  with  total  paralysis.  As- 
sociated with  paralysis  sartorius.  Loss  of  flexion  of  thigh.  Limb  extended 
(if  glutei  intact). 

Glutei. — Thigh  adducted.  Outward  rotation  lost.  Lordosis  on  stand- 
ing.    Frequent  association  with  paralysis  of  extensors  of  back. 

Quadriceps  Extensor. — Flexion  and  adduction  of  leg  (if  hamstrings 
intact).  Loss  of  extension  of  leg.  Frequent  association  with  paralysis  of 
tibialis  anticus. 

Tibialis  Aiiticus. — Often  concealed  if  extensor  communis  intact.  If 
both  paralyzed,  then  fall' of  point  of  foot  in  equinus.  Dragging  point  of 
foot  on  ground  in  walking.  Big  toe  in  dorsal  flexion  (if  extensor  pollicis 
intact).  The  tendons  prominent.  Hollow  sole  of  foot  (if  peroneus  longus 
intact) . 

Extensor  Communis. — Nearly  always  associated  with  that  of  tibialis 
anticus.     Toes  in  forced  flexion. 

Peroneus  Longus. — Sole  of  foot  flattened.  Point  turned  inward.  In- 
ternal border  elevated. 

Sural  Muscles. — Heel  depressed.  Foot  in  dorsal  flexion  (calcaneus). 
Sole  hollowed  if  peroneus  longus  intact;  flattened  if  paralyzed.  Point 
turned  outward   (calcaneo-valgus). 

Extensors  of  Bach. — Lordosis  on  standing.  Projection  backward  of 
shoulders.  Plumb-line  falls  behind  sacrum  (unilateral).  Trunk  curved  to 
side.    Trunk  cannot  be  moved  toward  paralyzed  side. 

Abdominal  Muscles.  —  Lordosis  without  projecting  backward  of 
shoulders. 


'•Starr.  American  Text-book  Diseases  of  Children,  p.  652. 


CEREBRAL  PARALYSIS.  799 

Rigidity  and  contractures  are  striking  symptoms  in  almost  all  these 
palsies,  and  for  this  reason  they  often  fall  into  the  hands  of  the  ortho- 
paedic surgeons,  who  are  besought  to  remedy  the  rigidly-flexed  elbows, 
wrists,  knees,  and  the  various  deformities  that  interfere  with  locomotion. 
Adductor  spasm  in  the  thighs,  causing  cross-legged  progression,  is  nearly 
constant  in  diplegia  and  paraplegia.  Talipes  equino-varus  is  the  most  fre- 
quent pedal  deformity  in  hemiplegia.  Earely  talipes  equinus  and  talipes 
equino-valgus  are  to  be  found  in  hasmiplegia.  While  rigidity  with  con- 
tracture is  the  rule  in  all  of  these  forms  of  infantile  cerebral  palsy,  occa- 
sionally, but  very  seldom,  cases  will  be  met  with  in  which  the  muscles  are 
all  completely  flaccid.  The  chief  trophic  disturbance  encountered  in  these 
cases  is  retardation  in  growth  of  the  paralyzed  member.  The  paralyzed 
limbs  do  grow,  but  at  a  much  slower  rate  than  the  sound  extremities. 
Hence  the  disproportion  is  often  very  striking.  The  earlier  the  onset 
of  the  palsy,  the  greater  is  this  disproportion.  Another  peculiarity  noted 
is  that  the  growth  of  the  whole  organism  is  to  a  certain  extent  inter- 
fered with,  the  injury  to  the  brain  seeming  to  stunt  development  and 
to  prevent  the  patient  attaining  his  normal  stature.  The  patients  are  more 
or  less  undersized  and  dwarfed.  Peterson  describes  a  case  in  which  the 
mother  brought  to  him  her  two  boys,  twins,  6  years  of  age,  for  the  exami- 
nation of  the  one  affected.  One  was  a  tall,  well-built  lad;  the  h^emiplegic 
boy  was  small-bodied  and  fully  seven  inches  shorter  than  his  healthy 
brother.  In  all  of  these  cases  the  muscles  of  the  paralyzed  and  undevel- 
oped extremities  react  normally  to  the  faradic  current.  There  is  no  re- 
action of  degeneration.  In  many  cases  the  affected  limbs  may  be  blue  and 
cold,  as  in  paralysis  of  the  spinal  type.  A  very  rare  phenomenon  in  these 
cases  is  a  hypertrophy  of  the  muscles,  usually  combined  with  athetosis. 

Asymmetry  of  face  and  skull  have  been  observed.  Peterson  and  E.  D. 
Fisher  have  called  attention  to  the  flattening  of  the  skull  on  the  side  op- 
posite the  paralysis  in  infantile  spastic  ha^miplegia. 

Differential  Diagnosis. — From  infantile  spinal  paralysis  we  can  dif- 
ferentiate, by  the  presence  of  the  exaggerated  reflexes,  the  rigidity  and 
normal  reaction  of  the  muscles.  In  cerebral  palsy  there  is  no  actual  atrophy 
in  the  limbs.  When  the  central  neuron  is  involved,  the  inhibitory  influence 
over  reflex  manifestation  is  lost;  consequently  there  is  an  increased  reflex. 
When  the  peripheral  neuron  is  involved,  the  circuit  being  broken,  the  reflex 
is  lost.    There  are  no  marked  trophic  changes. 

Prognosis  and  Course. — In  diplegia  and  paraplegia  due  to  intra-uterine 
or  birth^  lesions  they  rarely  reach  the  third  year.  As  a  rule  they  die  of 
marasmus  in  infancy.  In  ha^miplegia  the  prognosis  is  better.  In  most 
cases  the  paralysis  may  improve  and  the  brain  may  not  be  seriously  im- 


^  See  article  on  "Eib's  Paralysis  or  Birth  Palsy  in  the  New-born  Baby.' 


800  DISEASES  OF  THE  XERVOUS  SYSTEM. 

paired.  If  epilepsy  appears  in  later  life,  we  may  suspect  a  previous  infan- 
tile paralysis. 

The  palsy  affecting  the  face  and  the  leg  can  usually  be  improved. 
Speech  will  also  gradually  return  if  improvement  is  noted.  The  late  ap- 
pearance of  epilepsy  must  not  be  forgotten.  Sometimes  the  paralysis  is 
present  a  year  or  more  before  the  onset  of  the  epilepsy  (Peterson). 

Treatment. — If  convulsions  are  present,  the  inhalation  of  chloroform 
or  laughing  gas  is  indicated.  Anti-spasmodics,  such  as  bromide  of  potas- 
sium or  bromide  of  sodium,  with  or  without  chloral  hydrate,  can  be  given. 
General  attention  to  the  stomach  and  bowels — and  dietetic  management 
is  certainly  indicated.  Iodide  of  sodium  is  also  indicated.  Counter-irritants 
cause  excitement  and  sometimes  do  harm.  J.  Madison  Taylor  advises 
against  the  use  of  counter-irritants.  Electricity  combined  with  massage 
is  useful.-  The  faradic  interrupted  current  will  do  good  by  stimulating  the 
muscles.  The  current  should  be  used  daily;  besides  careful  massage 
(muscle  kneading),  passive  movements  are  of  great  importance.  This  form 
of  exercise  should  be  resorted  to  and  more  good  can  he  done  by  this  form  of 
treatment  than  by  aU  medication.  We  must  not  expect  the  bodily 
functions  to  return  to  normal  until  we  have  strengthened  the  body  with 
restorative  treatment,  combined  with  fresh  air,  and  by  all  means  light 
nutritious  food. 

Some  cases  will  not  yield  to  medicinal  treatment,  and  here  surgical 
procedure  has  been  advised.  Neither  trephining  nor  craniectomy  have  been 
successful.  Allen  Starr  reports  in  a  recent  paper  that  in  fifty  cases  oper- 
ated, in  these  and  allied  conditions,  the  results  were  not  encouraging, 

A  child  3  years  old  was  brought  to  my  clinic  at  the  New  York  Post-graduate 
Medical  School  and  Hospital  in  1894.  It  was  suffering  with  backward  development 
and  had  distinct  evidences  of  cerebral  palsy.  There  was  a  diplegic  paralysis.  The 
head  was  microcephalic.  As  nothing  could  be  done  by  general  routine  treatment,  it 
was  decided  to  try  surgical  treatment.  A  craniectomy  was  performed  by  Dr. 
Seneca  D.  Powell.    The  child  died. 

Two  other  cases  known  to  me  have  been  operated,  and  the  surgical 
treatment  in  each  has  been  disappointing. 

Pleuroplegia  (Mobius'sche  Kernschwund)  . 

This  is  a  congenital  condition  caused  by  a  combination  of  abducens, 
facial,  and  hypoglossal  paralysis. 

This  condition  is  caused  by  nuclear  defects,  and  the  partial  palsies 
are  evidently  due  to  lack  of  intra-uterine  development.  The  following 
case  illustrates  this  condition: — 

C.  M.  G.J  born  May  4,  1898,  was  referred  to  me  for  diagnosis  by  Dr.  Henry  A. 
Bernstein. 

Family  History. — It  is  the  first  child.     The  mother  has  had  two  miscarriages 


PJja  KOlMJXilA. 


801 


since  the  birth  of  tliis  child.  The  parents  are  not  related  by  birth.  Syphilis  can 
be  positively  excluded. 

Child' n  Historu. — She  was  brea.'it-fed  for  three  months;  later  received  bottle 
feeding.  When  five  months  old  it  was  noticed  that  tlie  infant  could  not  support  its 
head.  Dentition  began  at  seven  and  one-half  months.  Did  not  walk  until  the  third 
year,  liud  measles  and  also  diarrhosa  about  this  time  and  ceased  walking,  but  began 
to  walk  again  during  the  fifth  year.  Talking  began  when  5  years  old.  Could  not 
connect  words  until  G  years  old.  Is  inclined  to  constipation.  Adenoids  were  re- 
moved when  3  years  old. 

St.  pr. — Now  7  years  old.  The  heart  sounds  are  clear  and  normal,  although 
heart  action  is  slow  (bradycardia).  The  head  moves  nonnally.  There  is  a  funnel- 
shaped  depression^  of  the  thorax,  also  a  spinal  curvature,  pendulous  belly,  carious 
teeth,  besides  other  symptoms  of  rickets.  Tlie  nasolahlai  folds  are  totally  absent. 
There  is  an  absence  of  expression — no  difference  in  laughing  or  crying.  The  saliva 
flows  out  of  the  mouth.  The  eyes  do  not  close  during  sleep  (lagophthalmus).  The 
iris  disappears  under  the  lids  in  attempting  to  close  them.  There  is  an  absence  of 
the  secretion  of  tears.  No  fibrillary  contractions  of  the  tongue  are  visible.  The 
uvula  is  in  the  median  line  just  as  in  the  normal  child. 

Treatment. — Restorative  treatment  consisting  of  proteid  food  and  general 
hygienic  treatment  to  improve  the  rachitis  was  ordered. 

Codliver-oil  and  phosphorus  may  be  tried,  as  also  large  doses  of  iodide 

of  sodium.     Faradic  electricity  is  indicated. 

Pseudohypertrophic  Paralysis  (Muscular  Pseudohypertrophy). 

We  are  indebted  to  Duchenne  for  an  accurate  clinical  description  of 
this  condition. 

Etiology. — This  disease  is  usually  found  in  children  between  the  sec- 
ond and  eighth. years.  It  is  more  frequently 
observed  in  males  than  in  females.  There  is 
no  distinct  cause  of  this  disease. 

Pathology. — The  pathological  lesions 
noted  are  a  fatty  infiltration  of  the  muscles, 
changes  in  the  breadth  and  contour  of  the 
muscular  fibers,  and  an  increase  in  the  inter- 
muscular connective  tissue. 

Symptoms. — Motor-weakness  is  usually 
the  first  thing  noticed.  A  child  apparently  in 
good  health  will  complain  of  inability  to  walk. 
At  the  same  time  there  will  be  an  enlarge- 
ment of  certain  groups  of  muscles.  In  cases 
seen  by  me  the  muscles  of  the  calves  were 
almost  as  large  as  those  of  the  thighs.  .Stew- 
art has  reported  cases  in  which  the  calves  of 
the  child  were  as  large  as  those  of  an  adult. 
The  muscles  most  frequently  affected  are  the 
deltoids,  biceps,  trieepi,  latissimus  dorsi,  and 
sterno-mastoids. 

51 


Fig.   267. — Pseudohypertrophic 
Paralysis. 

I  am  indebted  to  Dr.  Dexter  Ashley  for  tlio 
above  illustratiou. 


802  •  DISEASES  OF  THE  KERVOUS  SYSTEM. 

Duchenne  has  found  all  of  the  muscles  of  the  body  hj^pertrophied. 
After  the  hypertrophj"  disappears  it  is  succeeded  b}^  an  atrophic  condition. 
There  is  less  muscular  irritability  with  faradic  and  galvanic  currents.  The 
patellar  reflex  is  usually  absent  as  the  disease  progresses. 

Case  I. — A.  L.,  6  years  old,  boy.  As  a  baby  the  mother  noted  that  there  was 
something  the  matter.  Walked  at  2  years  of  age.  Child  was  very  fat,  and  had  a  good 
appetite  at  that  time.    Now  eats  but  little. 

Walks  very  erect,  in  soldier-like  position,  almost  suggesting  Pott's  disease. 
St«ps  slowly.  On  table,  first  noted  apparently  strong  muscular  development  of  the 
back.  Muscles  of  back,  thigh,  calves,  apparently  well-developed.  Child  rises  from 
the  floor  with  characteristic  movements.  Flat-footed.  Cannot  get  up  without  roll- 
ing over,  when  reclining  on  back.  Child  looks  to  be  in  good  health.  Father  says 
he  is  constantly  growing  weaker,  slowly.  Came  to  me  for  diagnosis,  not  having 
previously  known  the  nature  of  the  condition. 

Case  II. — Jacob  S.,  was  first  seen  by  me  when  12  years  old.  Walking  became 
impaired  at  the  age  of  6  years,  gi-adually  getting  worse,  so  that  to-day  he  cannot 
walk  at  all.  The  refieses  are  absent.  Sensation  is  impaired.  The  spinal  muscles 
in  dorsal  region  are  atrophied.  Gastrocnemii  markedly  increased  in  size.  The 
extreme  difficulty  of  rising  from  a  sitting  position  is  very  characteristic.  (Fig.  270.) 
The  loss  of  power  in  arms  is  quite  marked  also.  A  history  of  diphtheria  is  given 
just  prior  to  the  onset. 

Dr.  L.  S.  Manson  kindly  referred  this  case  to  me. 

Pro^osis. — The  prognosis  as  a  rule  is  bad. 

Treatment. — The  treatment  consists  in  restoratives.  Massage  may  be 
tried.  Such  a  case  should  always  be  sent  to  a  neurologist  to  outline  the 
future  course  of  treatment. 

Facial  Paealtsis  in  the  New-born. 

This  condition  is  most  frequently  seen  in  the  new-born  after  the  use 
of  the  forceps.     It  is  a  peripheral  paralysis  resulting  from  traumatism.     It 

is  the  result  of  pressure  on  the  nerve  near  the 
exit  through  the  stylo-mastoid  foramen  or  where 
the  facial  nen^e  crosses  the  ramus  of  the  Jaw. 
The  parotid  gland  gives  little  protection  in  the 
new-born.  The  paralysis  is  most  frequently 
unilateral^  as  usually  only  one  blade  of  the 
forceps  causes  injury. 

Fig.    268.— Facial  Par-  FACIAL    PARALYSIS     (BeLL's    ParALTSIS). 

alysis    following    Mastoid 

Operation.     (Original.)  This    is    frequently    called    post-operative 

palsy.     This  disease  may  follow  mastoid  opera- 
tion.     It    may    also    follow    retropharAngeal    abscess    (Bokai). 

The  disease  is  sometimes  associated  with  tumor  in  the  cerebellum. 
Prognosis  and  Course. — Great  care  should  be  exercised  in  expressing 


PSEUDOHYPERTROPHIC  PARALYSIS. 


803 


Fig.  269. 


Fig.  270. 


PSEUDOHYPEETROPHIC 
PABAiYSIS. 

Fig.  269. — Note  hyper- 
tropliie  condition  of  the 
muscles  of  the  legs.  Can- 
not stand  without  strong 
support.      (Original.) 

Fig.  270. — ^Attempting 
to  rise  from  chair.  Com- 
pare atrophy  of  muscles 
of  arms  and  spine  with 
liypertrophy  of  muscles 
of    legs.       (Original.) 

Fig.  271. — Attempting 
to  rise  from  floor.  Can 
raise  the  body  no  higher. 
(Original.) 


Fig.   271. 


804  DISEASES  OF  THE  NERVOUS  SYSTEM. 

an  opinion  as  to  the  outcome  of  a  case  of  facial  palsy.  In  one  case  seen 
by  me  after  a  mastoid  operation  a  permanent  palsy  remained.  I  saw  the 
case  four  years  after  the  operation. 

Treatment. — This  depends  on  the  cause.  Eestorative  treatment  aided 
by  massage  and  electricity  should  be  tried.  Unless  some  improvement  is 
noted  within  a  few  weeks  the  outcome  of  the  case  will  be  serious. 


Abscess  of  the  Brain  (Cerebral  Abscess). 

This  condition  is  occasionally  seen  in  children. 

Etiology. — There  are  two  principal  causes  of  this  condition :  first, 
traumatism — injury  to  the  head  by  a  blow  or  a  fall,  resulting  in  fracture 
of  the  skull  or  in  abscess;  second,  from  an  extension  of  middle-ear  abscess 
into  the  mastoid  cells,  so  that  an  abscess  of  the  cerebellum  results.  The 
infection  is  carried  through  the  veins  or  usually  along  the  lateral  sinuses 
to  the  cerebellum.  Wagner  reported  a  case  of  cerebral  abscess  in  which 
thrush  was  believed  to  be  the  cause. 

The  white  substance  of  the  brain  is  usually  affected  in  this  suppura- 
tive process.  It  is  rarely  seen  in  children  under  1  year  of  age,  but  more 
frequently  between  the  ages  of  1  and  10  years.  Out  of  233  cases  reported 
by  Gower,  24  occurred  between  the  ages  of  1  and  9  years.  Korner's  statis- 
tics show  that  out  of  77  cases  of  brain  abscess,  25  were  secondary  to  ear 
disease. 

In  38  out  of  40  cases,  according  to  Korner,  the  bone  itself  is 
diseased. 

Pathology. — Meyer  reports  a  case  of  abscess  which  occupied  an  entire 
hemisphere.  The  pus  found  is  usually  greenish-yellow.  At  times  the 
abscess  may  be  encysted,  in  which  case  it  is  surrounded  by  a  pyogenic  mem- 
brane. Lalemand  reports  a  case  of  abscess  of  the  brain  in  which  there  was 
an  escape  of  pus  through  the  auditory  meatus.  "The  most  frequent  seat  of 
the  abscess  is,  first,  the  temporo-sphenoidal  lobe;  second^,  the  cerebellum;, 
thirdly,  the  frontal  lobes.  Other  locations  are  very  rare.  Abscesses  are 
usually  single.     In  size  they  vary  from  that  of  a  cherry  to  an  orange." 

"Abscess  of  the  brain,  as  well  as  meningitis  and  sinus-thrombosis  sec- 
ondary to  otitis,  begin,  as  a  rule,  at  a  point  corresponding  to  that  at  which 
the  inner  surface  of  the  bone  is  attached.  The  roof  of  the  tympanum 
enters  into  the  middle  fossa,  and  the  bony  partition  is  sometimes  as  thin 
as  writing-paper;  it  is  for  this  reason  that  disease  of  the  middle  ear  most 
often  causes  abscess  in  the  temporo-sphenoidal  lobe  which  lies  on  the  fossa. 

The  mastoid  cells  are  separated  from  the  posterior  fossa  by  a  thin 
layer  of  bone,  and  hence  abscess,  secondary  to  disease  in  that  region,  is 
often  situated  in  the  cerebellum.  The  extension  of  the  disease  to  the  brain 
is  due  to  thrombosis  extending  from  the  diseased  bone,  or  from  the  ear. 


ABSCESS  OF  THE  BRAIN.  805 

through  the  veins  which  pierce  the  roof  of  the  tympanum;  only  rarely  is 
there  a  direct  communication  by  a  suppurating  tract.  In  common  with 
other  forms  of  intracranial  inflammation  due  to  ear  disease,  abscesses  occur 
more  often  on  the  right  tiian  on  the  left  side." 

Symptoms. — If  the  child  is  old  enough  to  complain,  there  will  be 
headaches  described  over  the  affected  area.  Fever  usually  accompanies  this 
condition.  The  temperature  may  rise  to  104°  or  105°  F.  in  the  beginning, 
although  cases  are  reported  where  the  temperature  remains  normal.  Vom- 
iting usually  accompanies  this  condition.  At  times  in  young  children  there 
are  convulsions,  coma,  opisthotonos,  and  all  symptoms  pointing  to  a  men- 
ingitis. When  distinct  areas  are  affected,  such  as  the  motor  areas,  then, 
paralysis  of  the  extremities  may  take  place.  Optic  neuritis  is  sometimes 
present.  A  choked  disc  can  sometimes  be  made  out  by  an  ophthalmoscopic 
examination.  If  the  bones  of  the  cranium  are  thin  then  there  is  usually 
marked  tenderness  over  the  region  of  the  abscess. 

A  foundling,  eleven  months  old,  was  in  a  fair  condition  when  first  seen  by  the 
foster  parents,  who  later  adopted  him.  This  infant  subsequently  developed  sore  eyes 
and  still  later  had  several  bruises  on  the  scalp  which  suppurated.  In  addition 
thereto  he  was  emaciated  and  showed  the  evidence  of  both  neglect  and  improper 
feeding.  The  infant  with  proper  feeding  and  hygienic  care  developed  into  a  bright 
healthy  boy.  He  attended  school  and  seemed  in  good  health  until  his  seventh  year, 
when  he  showed  signs  of  trouble  with  his  head.  Dr.  W.  B.  Chapin,  who  attended  him, 
suspected  caries  of  the  bones  back  of  the  ear. 

Dr.  W.  Freudenthal  was  called  in  consultation  with  Dr.  Chapin  to  see  the  swelling 
behind  the  ear,  which  had  developed  during  the  previous  eight  weeks.  The  swelling 
was  about  the  size  of  a  large  cherry,  there  was  no  pain  on  palpation  and  no  spas- 
modic contractions.  The  swelling  was  located  on  the  side  of  the  head  corresponding 
to  the  upper  lobe  of  the  ear.  It  was  not  reddened  and  fluctuated  on  palpation.  Ex- 
amination of  the  ear  showed  no  pathological  condition.  The  drum  membrane  was 
normal.     There  was  no  tenderness  over  the  mastoid. 

After  waiting  some  time  it  was  thought  advisable  to  open  the  abscess.  Tlie 
abscess  was  opened  by  Dr.  Freudenthal  with  general  anaesthesia.  Necrotic  tissue 
was  found,  but  the  mastoid  was  intact,  and  it  was  impossible  to  probe  the  mastoid 
cells;  however  it  was  found  that  a  small  probe  penetrated  in  the  direction  of  the 
frontal  lobe  to  the  depth  of  3  V*  inches.  Pus  oozed  from  this  opening.  As  this  was 
evidently  a  case  of  cerebral  abscess,  the  wound  was  dressed  and  the  further  operative 
procedures  left  to  a  surgeon.  The  temperature  ranged  between  99°  and  10472°  F. 
The  abscess  was  on  the  right  side  of  the  head.  Convulsions  occurred  on  the  left 
side  of  the  body.  Dr.  A.  Gerster  was  called  in  and  diagnosed  the  case  as  a  cerebral 
abscess.  On  the  following  morning  an  operation  was  performed.  To  be  sure  that 
the  mastoid  was  not  involved,  part  of  the  mastoid  was  opened.  It  was  found  normal. 
Two  ounces  of  pus  were  evacuated  from  the  abscess.     The  case  ended  fatally. 

Diagnosis. — This  is  usually  made  when  suppuration  of  the  middle  ear 
existed  prior  to  this  attack.  If  opisthotonos,  symptoms  of  coma,  convul- 
sions, high  fever,  or  vomiting  follow  an  attack  of  acute  or  sub-acute  olitis, 


g06  DISEASES  OF  THE  NERVOUS  SYSTEAL 

then  an  extension  of  the  suppurative  process  should  he  suspected.  At  times 
the  diagnosis  will  tax  the  ingenuity  of  the  most  expert  aurist. 

Prognosis. — This  is  always  grave.  Our  only  chance  for  saving  life  is 
to  resort  to  an  early  operation. 

Treatment. — The  earlier  surgical  relief  is  instituted,  the  better  will 
be  the  result.  The  medicinal  treatment  consists  in  relieving  symptoms 
such  as  fever  by  means  of  an  ice  coil,  and  by  active  catharsis.  Eelieve  the 
nervous  s}"mptoms  with  the  aid  of  large  doses  of  bromide  and  chloral.  Coni- 
l^lete  details  of  brain  surgery  are  given  by  M.  Allan  Starr  in  his  book  on 
"Brain  Surgrerv." 


Alalia  Idiopathic a^  (Backwaedxess  ix  Speakixg). 

When  a  child  is  in  good  health  and  does  not  learn  how  to  speak, 
careful  examination  is  necessary.  In  such  cases  it  is  important  to  exclude 
idiocy.  Although  some  children  do  not  speak  before  they  are  2  or  3  years 
old,  their  general  habits  and  mannerisms  will  easily  show  whether  or  no 
we  are  dealing  with  mental  disease. 

The  prognosis  is  excellent,  although  frequently  parents  will  be  very 
anxious  and  worried  regarding  the  outcome. 

Treatment. — Persistent  teaching  will  usually  remedy  this  condition. 

Idiocy  axd  liiBECiLiTT. 

In  idiocy  we  have  a  congenital  absence  of  mentality  and  intelligence. 

In  imbecility  we  have  an  arrested  development  or  a  partial  arrest  of 
development. 

Etiology. — According  to  Shuttleworth  prolonged  labor  without  in- 
strumental interference  is  the  cause  of  idiocy  in  29  per  cent,  of  cases 
admitted  to  his  asylum.  Down  states  that  of  2000  idiots  examined  by  him 
there  were  symptoms  of  suspected  inanition  at  birth  in  20  per  cent.  This 
writer  also  states  that  disturbance  of  the  mother's  physical  condition  dur- 
ing pregnancy  resulted  in  mentally  deficient  offspring  in  about  20  per 
cent.  Griesinger  states  that  "violent  shock  and  grief  during  pregnancy 
appear  not  to  be  without  influence  as  a  cause  of  idiocy."  Consanguinity  is 
a  much  disputed  point.  Some  authors  believe  that  blood  relations  in- 
variably have  mentally  deficient  offspring.  Other  equally  observant  writers 
hold  the  opposite  view.  I  have  seen  a  ease  of  idiocy  in  which  the  father 
and  mother  were  first  cousins.  Children  of  intemperate  parents,  and  chil- 
dren of  s}-philitic  and  tubercular  parents  are  frequently  found  to  be  men- 
tally deficient. 


*  Read  also,  "Very  Late  Speaking,"  Part  I,  page  3, 


IDIOCY  AND  IMBECILITY. 


807 


Shuttle-worth,  a  well-recognized  English  authority  in  this  field,  gives  the 
following  classification  of  idiocy : — 


Tahlp:  No.  7!).    • 

CLASS    A CONGENITAL. 


1.  Microcephalic. 

2.  Hydrocephalic     (also    non-congeni- 

tal). 

3.  Scrofulous.     "Mongol   type." 

4.  Sensorial    (also  non-congenital). 

5.  Primarily  neurotic. 

6.  Paralytic   (also  non-congenital). 

7.  Choreic   (also  non-congenital). 

8.  Cretinoid:      (a)   sporadic,   (6)    en- 

demic. 

CLASS  B — NON-CONGENITAL. 

(a)  Developmental. 

9.  Eclamptic. 

10.  Epileptic. 

11.  Syphilitic. 

12.  Post-febrile   (also  accidental). 

(b)  Accidental  Or  Acquired. 

13.  Toxic. 

14.  Traumatic. 

15.  Emotional. 


16.  From  mixed  causes. 

Symptoms  and  Diagnosis. — 

Great  care  must  be  taken  in  dif- 
ferentiating   between    backward- 
ness and  idiocy.     A  child  that  is 
backward    in    development    does 
not  remain  stationary  in  develop- 
ment, but  progresses  very  slowly 
in   comparison  with   children   of 
the   same   age;    for   example,   a 
backward  child  of  5  or  6  years 
will  show  the  mental  development  of  a  child  but  2  or  3  years  old.     In  such 
a  case  we  deal  with  a  slow  mental  progress,  whereas  an  idiot  shows  a  distinct 
arrest  of  development,  both  of  body  and  mind. 

Down  describes  Mongolian  idiocy  in  the  following  language:  "The 
hair  is  not  black  as  in  the  real  Mongol,  but  of  a  brownish  color,  straight 
and  scanty;  the  face  is  fiat  and  broad,  and  destitute  of  prominence;  the 
cheeks  rounded  and  extended  laterally;  the  eyes  obliquely  placed,  and  the 
internal  canthi  more  than  normally  distant  from  one  another  (the  epi- 
canthic  fold  often  abnormally  large)  ;   the  palpebral  fissure  very  narrow; 


Fig.  272. -ConKenital  Idiocy  (Lillie  B.).  Age  6 
years.  Deliuate  until  4  years  of  age.  Did  not  walk 
until  the  fourth  year;  Mother  cannot  tell  when 
difference  in  the  two  sides  was  first  noted.  There 
were  no  convulsions.  The  head  measured  19  inches. 
There  were  strabismus,  and  deformed  jaws.  The 
mouth  was  constantly  open.  Kight  hemiplegia, 
more  marked  in  upper  extn^mity.  Walks  and  runs 
around,  but  drags  right  foot.  Contracture  and 
spasticity  present.  Expression  idiotic.  Has  never 
talked.  Intelligence  ?ij7.  Is  restless  and  in  nearly 
constant  motion,    (Case  of  Dr,  A.  C.  Cotton.) 


808 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  forehead  wrinkled  transversely,  from  the  constant  assistance  which  the 
levatores  palpebrarum  derive  from  the  occipito-frontalis  muscle  in  the 
opening  of  the  eye;  the  lips  large  and  thick,  with  transverse  fissures;  the 
tongue  long,  thick,  and  much  roughened;  the  nose  small;  the  skin  has  a 
slightly  dirty,  yellowish  tinge,  and  is  deficient  in  elasticity,  giving  the 
appearance  of  being  too  large  for  the  body. 


Fig.  273.— Imbecile  (Louie  W.).  Showing 
anterior  curve  of  the  spine  and  general 
atrophy  of  all  the  muscles,  especially 
those  of  the  back  and  shoulders. 
(Original.) 


Fig.  274. — Imbecile  (Louie  W.).  Showing 
normal  position  of  head  flexed  on  the 
chest.  Can  only  lift  head  by  raising  chin 
with  extensor  muscles  of  hand  and  fore- 
arm.     (Original.) 


"This  type  occurs  in  more  than  10  per  cent,  of  cases;  they  are  always 
congenital  idiots;  they  have  considerable  power  of  imitation;  they  are 
humorous;  they  are  usually  able  to  speak,  the  co-ordinating  faculty  is 
abnormal;  the  circulation  is  feeble;  the  improvement  which  training 
effects  is  greatly  in  excess  of  what  would  be  predicated  if  one  did  not 


IDIOCY  AND  IMBECILITY. 


809 


know  tlie  characteristics  of  this  type;  the  life-expectancy  is,  however,  far 
below  the  average,  and  the  tendency  is  to  tuberculosis." 

These  children  are  usually  found  to  be  deaf,  blind,  or  to  have  some 
deformity  of  the  mouth,  nose,  hands,  or  feet.  I  have  seen  cases  of  this 
kind  in  my  Pcrvioe  at  the  various  hospitals  of  New  York,  and  also  re- 


Fig.  275. — Imbecile  (Louie  W.). 
Showing  position  assumed  in  walking. 
Cannot  stand  on  feet.      (Original.) 


Fig.    276. — Imbecile      (Louie     W.). 
Showing  drop  wrist  and  foot.      (Original. ) 


member  seeing  this  form  of  disease  at  the  Children's  Klinik  of  Dr.  Hugo 
Neumann,  at  Berlin.    This  disease  usually  ends  fatally. 

I  allude  to  infantile  amaurotic  idiocy  on  page  810.  Other  forms 
of  mental  impairment  are  described  in  detail  (see  article  on  "Sporadic 
Cretinism,"  page  719). 


810  DISEASES  OF  THE  NERVOUS  SYSTEM. 

An  Imbecile  Having  Miceocephaly  and  Pseudo-musculab  Atbophy. — ^Louie 
W.,  5  years  old,  was  referred  to  me  through  the  courtesy  of  Dr.  L.  S.  Manson. 

Previous  History. — This  child  was  bom  at  fuU  term,  natural  labor,  no  forceps. 
He  was  breast-fed  about  15  months ;  could  not  stand,  walk  nor  talk  until  2  years  old. 
Dentition  began  during  the  ninth  month,  which  was  very  early  in  this  family,  as  all 
the  other  children  teethed  at  fifteen  months.  He  had  measles  when  2  years  old, 
influenza  and  pneumonia  when  3  years  old.  The  boy  has  an  imusually  small  skull, 
16  inches  in  circumference;    the  normal  circumference  at  this  age  is  about  21  inches. 

Family  History. — The  mother  had  been  married  twice,  had  six  children  with  the 
first  husband  and  five  with  the  second.  Three  children  died  of  scarlet  fever.  The 
rest  of  the  children  are  strong  and  healthy.  There  is  no  family  history  of  idiocy  or 
nervous  disease  on  either  father's  or  mother's  side. 

The  mother  first  noticed  trouble  when  the  child  was  2  years  old,  when  he 
began  to  go  about  on  his  knees,  having  never  walked  on  his  feet.  He  has  no  power 
in  the  hands  or  feet;  speaks  very  little,  voice  tremulous.  Tic  of  small  muscles  of 
chin;  knee-jerk  both  present.  There  is  great  muscular  weakness  of  the  lower  ex- 
tremities and  muscles  of  the  back.  There  was  drop-wrist  and  foot  and  universal 
wasting  of  the  muscular  system  without  marked  trophic  changes.  Normal  position  of 
[head  is  that  of  fiexion  on  chest  and  can  only  lift  head  by  raising  chin  with  extensor 
muscles  of  hand  and  forearm.  Fibrillary  twitching  of  all  the  muscles  in  hands  not 
amounting  to  athetosis. 

Infantile  Amatjeotic  Family  Idiocy. 

This  peculiar  condition  has  attracted  considerable  attention  in  recent 
years.  In  1881  Tay,  of  England^  described  a  case  of  symmetrical  changes 
in  the  macula  lutea.  The  child  could  not  sit  erect  and  was  backward  men- 
tally. John  Claiborne,  reviewing  this  subject  in  1900,  refers  to  the  above 
case,  and  says: — 

"At  the  first  examination  the  optic  disc  was  normal,  but  at  the  macula 
there  was  a  white,  more  or  less  round  area,  in  the  center  of  which  was  a 
brown  spot.  The  picture  was  similar  to  that  seen  in  embolism  of  the 
central  artery  of  the  retina.  Tay  at  first  thought  it  was  a  congenital 
change.  Five  months  later  he  noticed  the  optic  disc  was  atrophied.  Three 
months  later  he  observed  3  other  cases  in  the  same  family.  In  alt  the 
ophthalmoscopic  picture  was  the  same,  and  all  these  persons  died  before 
•  the  end  of  the  second  year  of  the  disease.  During  the  years  1885  and 
1886  the  same  ophthalmoscopic  picture  was  described  by  Magnus,  Knapp, 
and  others.  In  1887  Sachs  reported  a  case  which  impressed  him  as  being 
one  of  idiocy;  this  was  particularly  interesting  on  account  of  the  changes 
observed  in  the  cortical  cells.  The  family  character  of  the  affection  was 
suggested  to  him  after  observing  4  cases  in  two  families.  Kingden,  of 
England,  published  a  case  and  showed  a  picture  which  eye  surgeons  said 
belonged  to  the  disease  which  Sachs  had  elucidated.  In  1898  Sachs  re- 
viewed the  subject,  tabulating  29  cases." 

A.  Jacobi  reported  3  cases  of  this  form  of  idiocy  to  the  American  Ped- 
iatric Society  in  1898. 


CONCUSSION  OF  THE  BRAIN.  811 

Pathology. — Sachs  states  that  the  external  configuration  of  the  brain 
exhibits  a  distinct  picture  of  a  lower  order  of  development.  It  is  difficult 
to  state  wliether  the  chano;Gs  were  to  be  regarded  as  primary  degenerations 
or  due  to  an  arrest  in  development. 

Symptoms  and  Diagnosis. — There  is  "a.  milky-blue  or  white  optic  disc 
witli  bright  clierry-red  center  occupying  the  place  of  the  macula  lutea." 
Nystagmus  is  frequently  present.  Hydrocephalus  has  been  reported  asso- 
ciated with  this  condition.  The  weakness  of  the  extremities  increases  slowly 
until  diplegia  appears.  In  such  cases  the  optic  symptoms  and  idiocy  are 
pronounced,  and  from  these  two  conditions  alone,  the  diagnosis  can  be 
made.  The  voluntary  muscles  are  relaxed,  especially  those  of  the  ab- 
domen. Death  usually  comes  at  the  end  of  the  second  or  third  year, 
although  the  disease  may  last  years.    The  child  is  totally  blind. 

Treatment. — No  treatment  has  as  yet  modified  or  benefited  these 
children. 

Concussion  of  the  Brain. 

We  frequently  see  children  who  have  fallen  down  a  flight  of  stairs,  or 
with  apparently  as  severe  sjonptoms,  that  will  recover.  The  following  case 
illustrates  concussion  of  a  mild  type  which  recovered: — 

Case  I.— A  boy,  7  years  old,  rolled  down  a  flight  of  stairs.  I  saw  him  about 
one  hour  after  his  fall.  There  was  nausea  and  vomiting.  Some  slight  abrasions  of 
the  skin  were  present,  and  a  scalp  wound  one  inch  in  length  which  required  a  stitch. 
The  temperature  was  100°  F.  The  boy  was  put  to  bed.  I  saw  him  about  twelve 
hours  later.  He  was  perfectly  normal  and  complained  of  intense  hunger.  On  the 
following  day  the  boy  was  apparently  well. 

Case  II. — Severe  Concussion  of  the  Brain. — Child  S.  was  seen  by  me  through 
the  courtesy  of  Dr.  E.  D.  Lederman,  with  the  following  history:  He  was  in  his  fourth 
year,  bottle-fed  during  infancy,  and  excepting  an  occasional  attack  of  dyspepsia,  had 
always  enjoj-ed  good  health. 

Present  Condition. — Three  days  before  I  saw  him  he  fell  and  struck  his  head 
violently  on  the  pavement.  Six  hours  later,  severe  vomiting  set  in.  During  the  night 
following  the  fall  he  was  feverish  and  moaned  continually.  On  the  following  day 
when  Dr.  Lederman  saw  him  the  temperature  was  103°  F.  Tlie  child  seemed  to  be 
dazed  and  in  a  stupor  at  times.  He  was  very  thirsty.  There  were  marked  evidences 
of  clonic  and  tonic  spasms  in  the  muscles  of  the  body.  A  laxative  was  ordered.  The 
gastro-intestinal  tract  was  cleaned  and  an  ice-bag  applied  to  the  head.  These  same 
symptoms  continued,  the  fever  rose  to  105°  F.  and  was  not  easily  reduced.  When  I 
saw  him  in  consultation  with  Dr.  Lederman  there  were  spastic  conditions  of  the 
muscles  of  the  arms  and  legs.  There  was  marked  rigidity  of  the  spine.  The  sterno- 
cleido-mastoid  muscles  were  rigid.  There  was  marked  opisthotonos.  Severe  photo- 
phobia. The  pupils  were  dilated  and  did  not  respond  to  a  strong  light.  The 
Babinski  reflex  was  present  on  the  right  side,  but  not  so  positive  on  the  left  side. 
WTien  moved  about  the  child  moaned  as  though  in  pain.  A  tache  eerebrale  wa-s  also 
present.  The  diagnosis  of  concussion  and  traumatic  basilar  meningitis  was  made. 
A  lumbar  puncture  was  made  and  almost  one-half  ounce  of  turbid  (milky)  cerebro- 
spinal fluid  was  withdrawn.  The  child  passed  urine  involuntarily  (evidently  due  to 
bladder  paralysis ) .    The  case  ended  fatally. 


PART  X. 

DISEASES  OF  THE  EAR,  EYE,  SKIN,  AND  ABNORMAL 

GROWTHS. 


CHAPTEE  I. 
DISEASES  OF  THE  EAR. 


Acute  Catarrhal  Otitis  Media. 

Acute  catarrhal  otitis  media  arises  in  the  great  majority  of  cases  from 
extension  of  an  inflammatory  process  by  way  of  the  Eustachian  tube. 

Etiology. — Burkens  found  104  deaths  in  33,107  ear  cases,  and  Randall 
15  in  5000,  giving  a  percentage  of  three-tenths  of  1  per  cent,  from  intra- 
cranial disease. 

Schwartz  records  30  deaths  in  8425  ear  cases,  or  0.35  per  cent.  The 
death  rate  from  purulent  ear  diseases,  compared  with  all  other  diseases 
treated,  was  shown  in  Guy's  Hospital,  in  London,  some  years  ago,  to  be 
57  deaths  among  9000,  two-thirds  of  1  per  cent;  40,073  autopsies  in  the 
Vienna  General  Hospital  showed  232  deaths  from  otitic  complications,  i.e., 
0.58  per  cent.  The  majority  of  these  deaths  occurred  in  the  course  of 
chronic  suppuration  of  the  middle  ear,'  complications  in  the  acute  stage, 
with  the  exception  of  mastoiditis,  being  less  frequent. 

ISTaso-pharyngeal  disease,  especially  the  infectious  diseases,  such  as 
measles,  scarlet  fever,  influenza,  and  diphtheria,  are  frequently  fol- 
lowed by  otitis.  The  ease  with  which  pathogenic  bacteria  can  cause  an 
inflammatory  extension  from  the  nose  into  the  Eustachian  tube  is  now 
recognized.  Children  of  the  lymphatic  and  rachitic  types  are  more  sus- 
ceptible to  these  infections. 

When  a  catarrhal  process  limits  its  attack  to  the  lower  portion  of  the 
middle  ear  chamber,  the  disease  may  run  its  course  without  becoming 
purulent.  When,  however,  the  upper  part  or  tympanic  attic  is  involved, 
we  are  more  apt  to  find  that  the  infection  assumes  a  suppurative  type.  It 
is  ill  this  class  of  cases  that  complications  arise  and  extension  to  the  mas- 
toid cells  by  way  of  the  aditus  soon  follows. 

Bacteriology. — Observers  have  found  that  even  in  the  normal  tym- 
panic cavity,  pathogenic  bacteria  exist.  Consequently  any  deviation  from 
the  normal  process  in  this  region  predisposes  the  individual  to  a  purulent 
infection.  A  passive  congestion  of  the  tympanic  mucous  membrane  due  to 
(812) 


^LATK   XLir 


Normal  Mucous  Membrane  of  the  Middle  Ear  in  the  Xew-born. 


Inflammation  of  the  Mucous  iMembrane  of  tlie  Middle  Ear. 
Section  of  infiltration  with  polypoid  excrescences. 


•,       ^ 


^         X     / 


m 


Section  of  the  Vessel  of  the  jNIucous  Membrane  Containing  Streptococcus 
Pyogenes.      (After  S.  Weiss.) 


ACUTE    CATARRHAL    OTITIS    MEDIA. 


813 


cardiac,  renal,  naso,  or  naso-pharyngeal  disease,  must  be  considered  a 
potent  factor  in  the  production  of  a  suppurative  otitis.  Staphylococci, 
diplococci,  and  streptococci  have  been  found  in  the  naso-pharyngeal  space, 
and  it  is  reasonable  to  suppose  that  these  micro-organisms  are  apt  to  find 
their  way  into  the  Eustachian  tube  and  tympanitic  cavity  even  under  nor- 
mal conditions. 


Fig.    277. — Complication  of  Scarlet  Fever  seen  in  my  service  at  Riverside  Hospital. 

(Original.) 


A  study  of  this  case,  in  which  both  ears  were  discharging,  is  interesting.  The 
temperature  was  only  99  Vb°  F.  in  the  rectum.  This  proves  that  we  must  always  be 
on  the  lookout  for  suppuration  of  the  middle  ear  in  the  acute  infectious  diseases. 

Pathologry. — "^Ve  must  bear  in  mind  that  the  ossicular  chain  is  sur- 
rounded or  enveloped  by  folds  of  mucous  membrane,  and  when  this  tissue 
becomes  engorged  drainage  from  the  attic  is  difficult.  Consequently  our 
incisions  through  the  upper  and  posterior  portion  of  the  membrane  in  acute 
otitis  should  be  deliberate  and  somewhat  heroic,  otherwise  we  will  not 
accomplish  the  object  in  view,  i.e.,  drainage  from  that  portion  of  the  middle 
ear  which  is  most  likely  to  be  followed  by  disease  of  the  mastoid  antrum 
and  cells. 

Symptoms. — Two  prominent  symptoms  are  always  present;  one  is 
pain  and  the  other  fever.  The  infant  is  usually  very  restless,  rolling  the 
head  from  side  to  side  on  the  pillow  and  rubbing  the  hand  over  the  affected 


814 


DISEASES    OF    THE    EAE. 


ear.  At  times  the  nose  and  throat  will  also  be  inflamed.  Local  tenderness 
can  usually  be  made  out  on  pressure.  The  examination  of  the  middle  ear 
with  the  speculum  should  always  be  made  by  one  skilled  in  this  work. 

Symptoms  of  meningitis  are  frequently  jjresent  and  will  disappear 
when  proper  treatment  for  an  otitis  is  instituted.  I  have  frequently  seen 
a  case  of  persistent  high  fever,  during  the  course  of  a  scarlet  fever,  suddenly 
improve  after  the  drum-membrane  was  incised.  The  temperature  ranges 
between  100°  and  105°  F.  A  distinct  rise  of  temperature  does  not  always 
accompany  this  condition  as  is  usual  in  other  inflammatory  conditions. 

Diagnosis. — This  is  easily  made  by  one  skilled  in  examining  the  ears. 
When  a  doubt  exists  the  safer  plan  is  to  call  in  an  aurist  for  an  opinion. 
The  neglect  of  this  precaution  may  prove  a  serious  matter,  as  deafness  may 
follow. 

Prognosis. — The  prognosis  is  reasonably  good. 
We  must  not  be  too  positive  in  giving  a  good  prog- 
nosis, as  sometimes  fatal  results  follow  the  extension 
of  the  inflammatory  condition  from  the  middle  ear 
into  the  brain. 

Treatment. — Prompt  drainage  by  an  early  inci- 
sion through  the  bulging  membrane  is  the  treatment 
indicated.  To  further  drainage  under  such  condi- 
tions it  is  wise  to  douche  the  ear  with  hot  antiseptic 
solutions  at  a  temperature  of  108°  to  130°  F.,  using 
a  return  flow  cannula.  It  has  been  claimed  that  the 
higher  the  temperature  of  the  douche,  the  greater 
the  possibility  of  absorbing  the  threatening  mas- 
toiditis. 

Prophylactic  Treatment. — As  a  soothing  and  prophylactic  agent  after' 
incision  or  even  before  surgical  intervention  is  indicated,  a  carbolized  glyc- 
erine solution  acts  well  in  a  number  of  these  cases.  In  a  very  young 
child  a  2  per  cent,  solution  may  be  instilled  into  the  ear  after  the  same  has 
been  cleansed  with  a  douche,  every  two  hours.  This  may  be  increased  in 
strength  as  the  age  of  the  patient  progresses.  Oily  combinations  should 
never  be  used  as  local  agents  in  aural  disease.  They  are  apt  to  become 
rancid,  and  as  the  middle  ear  is  an  excellent  incubator,  affording  bacteria, 
plenty  of  heat  and  moisture,  infection  rapidly  occurs. 

General  Treatment. — Peroxide  of  hydrogen  or  dioxygen  is  a  valuable 
cleanser  and  deodorizer  when  the  perforation  of  the  membrane  is  large. 
The  same  remedy  may  cause  extension  of  a  purulent  otitis  if  the  aperture 
in  the  drum  is  small,  and  the  liberation  of  its  oxygen  causes  sufficient 
pressure  to  force  the  purulent  foci  backward  through  the  aditus.  Bulging 
of  the  upper  portion  of  the  membrane  with  a  protrusion  of  the  superior 
and  posterior  walls  of  the  external  auditory  meatus,  together  with  tender- 


Fig.   278.— Ear  Syringe. 


ACUTE    CATARRHAL    OTITIS    MEDIA. 

ness  over  the  mastoid  antrum  or  tip,  with  some  elevation  of  temperature, 
occurring  during  the  course  of  an  acute  otitis,  are  indicative  symptoms  of 
mastoid  involvement.  Extensive  disease  of  the  mastoid  cells  may  exist 
without  the  slightest  rise  in  temperature,  especially  if  the  acute  stage  of 
the  inflammatory  process  has  passed  by. 

We  may  safely  assume  that  in  all  cases  of  catarrhal  otitis  the  mucous 
membrane  lining  the  mastoid  antrum  is  involved  simultaneously  with  that 
of  the  middle  car,  as  it  is  part  of  the  same  tissue.  For  this  reason  blood- 
letting, done  under  aseptic  precautions,  should  be  carried  out  as  near  the 
cavity  as  possible;  therefore,  an  internal  Wilde's  incision  carried  through 
the  posterior  superior  quadrant  of  the  membrane  is  certainly  a  rational 
procedure. 

Restorative  treatment  such  as  iron,  codliver-oil.  Fowler's  solution,  be- 
sides concentrated  foods,  must  be  remembered.  Unless  we  assist  the  nu- 
trition of  the  body  we  cannot  expect  to  cure  the  disease.  If  the  symptoms 
increase  in  severity  and  the  temperature  persists,  the  dangers  associated 
with  mastoiditis  must  be  remembered,  and  the  skill  of  an  otologist  or  a 
surgeon  will  be  required. 

Mastoid  Operatiox  ox  Infants  and  Children. 

In  operating  on  infants  and  children  it  is  important  to  remember  cer- 
tain points  wherein  they  differ  from  adults.  These  briefly  mentioned  are 
the  following: — 

At  oirth,  in  the  mastoid  the  antrum  exists  as  the  only  cavity,  about 
the  size  of  a  small  pea;  the  process  is  not  formed  until  after  the  end  of 
the  first  year,  and  the  pneumatic  spaces  not  until  puberty. 

There  are  also  frequently  dehiscences  filled  with  fibro-cartilage  as  the 
squamo-mastoid  suture  is  not  ossified  at  birth.  So  when  making  the  pri- 
mary incision,  the  knife  must  be  used  gently  until  the  periosteum  is 
reached,  and  this  likewise  must  be  raised  with  the  greatest  care  to  prevent, 
in  such  cases,  the  instruments  slipping  into  the  cranial  cavity. 

In  curetting  after  opening  the  mastoid,  it  must  be  borne  in  mind  that 
the  bone  tissue  in  childhood  is  soft,  so  that  healthy  tissue  need  not  be 
sacrificed  unnecessarily. 

The  Operation. — During  the  operation,  strict  antisepsis  must  be  ob- 
served. The  space  around  the  mastoid  for  two  or  three  iijches  beyond 
should -be  shaved  'and  made  surgically  clean.  The  auditory  canal  should 
be  irrigated  with  a  bichloride  solution  of  1  to  1000.  Then  under  com- 
plete anassthesia,  with  a  scalpel,  curvilinear  incision  should  be  made  from 
end  of  the  mastoid  close  to  the  insertion  of  the  auricle  to  about  one-half 
inch  of  its  upper  border,  down  to  the  periosteum.     This  is  then  separated. 

The  bleeding  is  controlled  either  by  clamping  vessels,  or  with  gauze 
wrimg  out  of  hot  water.    An  Allport  retractor  or  one  of  its  modifications 


816  DISEASES  OF  THE  EAR. 

should  then  be  used,  which  not  only  answers  the  purpose  of  its  name,  but 
also  stops  the  oozing.  The  parts  should  be  separated  with  the  auricle 
held  forward  so  that  the  posterior  and  superior  walls  of  the  auditory  canal 
and  the  whole  field  of  operation  is  exposed  to  view. 

If  the  bone  is  bathed  in  pus  this  is  wiped  away  and  any  perforation 
is  examined  with  a  probe.  The  opening  is  enlarged,  either  with  a  spoon 
or  rongeur.  Should  no  perforation  or  sinus  exist,  then  the  antrum  should 
be  opened  either  with  a  flat  chisel  or  gouge  and  a  mallet.  The  supra- 
meatal  triangle  is  above  the  antrum.  This  is  made  by  drawing  one  line 
horizontally  with  the  superior  border  of  the  auditory  canal,  a  second  ver- 
tical one  with  the  posterior,  and  a  base  line  corresponding  with  the  curvi- 
linear line  between  these  points. 

The  chisel  should  be  used  gently  and  tangential,  and  the  bone  chipped 
away  in  small  sections,  always  working  downward,  forward,  and  inward. 
A  probe  should  be  used  to  determine  from  time  to  time  whether  the  antrum 
has  been  entered,  and  also  to  examine  the  cavity  made. 

As  soon  as  an  opening  has  been  made,  a  rongeur  should  be  used  to 
enlarge  it,  and  then  thoroughly  cleaned  out  with  a  Volkman's  spoon.  The 
space  leading  from  the  antrum  to  the  roof  of  the  tympanum,  that  is,  the 
aditus  and  attic,  should  be  carefully  cleaned  out  with  a  small  curette.  The 
antrum  should  then  be  carefully  extended  backward  until  the  lateral  sinus 
is  exposed  and  inspected  as  to  whether  its  appearance  is  healthy.  Its  pres- 
ence can  be  determined  by  its  bluish  appearance  and  the  soft  feel  to  the 
probe.  All  granulations  and  soft  tissue  having  been  cleaned  out,  the  parts 
are  gently  irrigated  with  a  bichloride  solution  of  1  to  5000,  normal  salt 
solution,  saturated  solution  of  boric  acid,  or  sterile  water  if  considered 
necessary.  The  wound  is  then  wiped  dry,  the  upper  and  lower  ends  can  be 
stitched  together,  and  the  rest  packed  somewhat  lightly  with  iodoform 
gauze.  Bury  this  gauze;  that  is,  do  not  let  it  project;  then  over  this 
draw  the  parts  together  and  apply  layers  of  sterile  gauze,  absorbent  cotton, 
and  a  bandage. 

After-treatment. — Unless  pain  or  a  rise  in  temperature  occurs,  it  is 
frequently  not  necessary  to  change  the  dressing  for  five  or  six  days.  Usually 
there  is  no  discharge  in  the  auditory  canal ;  if  there  is,  it  is  gently  irrigated 
or  wiped  out.  For  the  mastoid  wound,  a  dry  wiping  is  all  that  is  neces- 
sary usually,  and  a  dressing  of  sterile  gauze  used  lightly  packed.  This  can 
be  changed  every  two  or  three  days.  Granulation  tissue  of  course  must  be 
cauterized. 

Accidents  During  the  Operation. — Wounding  the  lateral  sinus  may 
cause  a  profuse  haemorrhage.  If  the  bony  cortex  has  been  sufficiently  re- 
moved, the  sinus  may  be  plugged  with  iodoform  gauze  and  the  operation 
completed.  The  sinus  whenever  exposed  should  be  kept  covered  with  iodo- 
form gauze  separate  from  the  rest  of  the  cavity  to  prevent  infection.     If 


ACUTK    CATAUKHAJ.    OTITIS    MEDIA. 


817 

the 


the  vessel  should  not  be  sufficiently  freed  from  the  bony  covering 
bleeding  may  prevent  the  completion  of  the  operation. 

Exposwre  of  the  Dura. — If  carefully  dealt  with,  this  is  not  a  matter 
of  much  importance,  if  the  part  is  kept  covered  with  iodoform  gauze  inde- 
pendent of  the  rest  of  the  wound.  If  the  dura  should  be  wounded  it  should 
be  opened,  cleaned,  and  sewed  up  with  fine  catgut  sutures. 

Facial  Faralysis. — In  operating,  this  condition  can  be  prevented  by 
not  interfering  with  the  lower  two-thirds  of  the  posterior   wall   of  the 


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Fig.  279. — ^A  Common  Type  of  Acute  Mastoid  Inflammation  Following 
Influenza.  Thore  was  a  double  otitis  before  the  extension  to  the  mastoid 
cells.  Note  the  fever  curve  folloAving  the  operations.  Case  recovered. 
(Original.) 


auditory  canal  and  the  facial  nerve  will  escape  injury.  Where  it  has  been 
slightly  injured,  the  function  of  the  nerve  is  usually  restored  within  four 
to  six  weeks. 

Francis  M.  C,  1  year  old,  suffered  with  gastric  disturbance,  poor  appetite  and 
symptoms  resembling  colic.  His  bowels  moved  sluggishly,  the  stool  was  greenish  and 
contained  mucus  and  undigested  particles  of  casein.  He  emaciated  owing  to  the 
non-assimilation  of  food.  From  the  history  I  learned,  that  the  child  has  had  fever 
accompanied  by  catarrh  of  the  nose  and  a  general  bronchitis  for  the  last  four  weeks. 
The  examination  of  the  body  showed  a  decidedly  rachitic  thorax  and  distended 
abdomen;  retarded  dentition  and  general  backwardness  in  development.  There  wus 
no  evidence  of  pulmonary  disease.  The  heart-sounds  were  feeble  and  a  haemic 
murmur  was  distinctly  heard  at  the  apex  of  the  heart  and  also  in  the  vessels  of  the 
neck.  The  child  perspired  very  freely.  The  temperature  was  102.4°  F.,  pulse  140, 
respiration  28.  The  throat  showed  enlarged  tonsils  and  also  adenoid  vegetations. 
This  latter  condition  was  reported  by  Dr.  Charles  D.  Manson.  Both  ears  were  dis- 
charging. The  child  was  very  restless,  moaned  and  fretted  continually  and  did  not 
sleep  at  night.  My  diagnosis  was  influenza,  subacute  gastric  catanh,  rachitis,  and 
mastoid  involvement.     Dr.  Edward  Dench  saw  this  case  at  my  request  and  corrobor- 


818  DISEASES  OF  THE  EAR. 

ated  the  diagnosis.  The  temperature  rose  to  103.6°  F.  The  right  mastoid  was 
opened  by  Dr.  Bench  at  the  New  York  Ear  and  Eye  Infirmary.  The  temperature 
came  down  by  lysis  to  normal.  Three  days  later,  while  the  child  was  doing  quite  well, 
the  temperature  again  rose  to  103.6°  F.  A  left  mastoid  was  suspected,  and  accord- 
ingly the  second  operation  was  performed.  On  the  day  following  the  operation  the 
temperature  rose  to  104.2°  F.,  and  an  acute  milk  infection  was  suspected.  With  the 
aid  of  mist,  rhei  et  sodii  and  a  diet  of  whey  only,  at  intervals  of  three  or  four  hours, 
the  stomach  symptoms  subsided,  and  four  days  later  the  child  was  removed  from  the 
hospital  to  its  home  in  a  normal  condition.  With  careful  asepsis  both  wounds  healed. 
The  child  gained  in  weight  and  within  one  month  had  entirely  recovered. 

Sinus  Theombosis. 

Mastoiditis  is  occasionally  followed  by  a  secondary  infection  of  the 
lateral  sinus. 

Symptoms. — There  is  usually  a  sudden  rise  in  the  temperature,  ranging 
from  100°  to  105°  or  106°  F.  The  temperature  rises  rapidly  and  falls 
rapidly.  Unusual  variations  will  be  noted  in  the  temperature  so  that  it 
will  drop  from  106°  to  98°  F.  and  again  rise  to  its  former  height.  Bactere- 
mia is  usually  present.  The  blood  shows  a  marked  leucocytosis  and  a  high 
polynuclear  percentage.    In  doubtful  cases  a  blood  culture  should  be  taken. 

Treatment. — ^The  treatment  is  surgical.  In  many  cases  resection  of  the 
jugular  vein  is  necessary.  The  outcome  of  the  case  depends  on  the  vitality 
of  the  child  at  the  time  of  operation. 

Serum  Treatment. — When  we  are  dealing  with  a  pneumococcus  infec- 
tion, an  injection  of  antipneumococcus  serum,  30  to  50  cubic  centimeters, 
may  do  good.  If  no  benefit  follows,  repeat  the  injection  in  twenty-four 
hours. 

The  serum  is  indicated  if  resistance  is  low  with  a  correspondingly  low 
leucocyte  count  in  the  early  stages  of  the  disease. 

Foreign  Bodies  in  the  Ear. 

Insects,  bugs,  cotton,  beads,  and  pieces  of  pencils  are  frequently  found 
in  the  meatus.  When  beans  or  peas  remain  they  swell  and  cause  painful 
pressure  symptoms.  The  specialist  should  invariably  be  consulted  rather 
than  risk  the  danger  of  traumatism  in  unsuccessful  attempts  at  removal. 
If  a  live  insect  or  bug  is  in  the  middle  ear,  pour  water,  oil,  or  alcohol  into 
the  ear.  If  the  insect  is  not  dislodged  by  this  means  try  Allen's  foreign- 
body  forceps. 


CHAPTER  II. 

DISEASES  OF  THE  EYE.» 

Acute  Catarrhal  Conjunctivitis. 

This  condition  is  usually  associated  with  infectious  diseases.  As  a 
rule  it  is  found  in  coryza,  the  acute  exanthemata,  influenza,  and  the  usual 
infections  due  to  pathogenic  bacteria  in  the  atmosphere. 

General  Plan  of  Cleaning  the  Eye  when  Secretion  Exists. — The  eyes 
should  be  thoroughly  cleansed  with  a  pledget  of  cotton  dipped  in  lukewarm 
water.     Then  use  a  drop  or  two  of  a  solution  of  cocaine : — 

IJ  Cocaine  hydrochlorate 10  grains 

Salicylic  acid   Vz  grain 

Distilled  water ; 1  ounce 

M.     Drop  into  the  eye  3  times  a  day. 

After  instilling  the  cocaine,  a  few  drops  of  a  2  per  cent.  argjTol 
solution  should  be  dropped  on  the  eyelid.  The  irritating  secretions 
should  be  wiped  away  as  frequently  as  possible.  A  weak  solution  of  bichlo- 
ride of  mercury,  1  to  5000,  applied  on  cotton,  will  best  serve  to  cleanse  the 
eye.     It  should  be  used  at  a  temperature  of  100°  F.,  hourly  if  necessary. 

A  solution  of  borax : — 

IJ  Biborate  of  soda 4  parts 

Distilled  water ; 100  parts 

Or:— 

IJ  Argyrol 1  part 

Distilled  water 100  parts 

are  very  good  cleansing  remedies. 

Peroxide  of  hydrogen,-  one-half  strength,  is  recommended  by  Stephen- 
son, to  be  used  three  times  a  day. 

Atropia  is  simply  mentioned  to  be  condemned.  Protargol  and  larcjin 
stain  the  conjunctiva  and  are  useless.     To  prevent  the  lids  from  gluing 


'  The  correction  of  Errors  of  Refraction,  such  as  astigmatism  by  means  of  eye- 
glasses, and  the  treatment  of  strabismus,  should  only  be  undertaken  by  the  specialist. 
The  reader  is  refeiTed  to  special  works  on  Diseases  of  the  Eye  for  particulars  regard- 
ing these  conditions. 

-  A  good  preparation  on  the  market  is  called  dioxygen. 

(819) 


820  DISEASES  OF  THE  EYE. 

together  the  yellow  ozide  of  mercury  ointment  should  be  applied  two  or 
three  times  a  day : — 

IJ  Yellow  oxide  of  mercury  ( 5  per  cent. ) 1  part 

Vaseline   ■. 10  parts 

Lanoline 10  parts 

Pink  Eye, 

This  form  of  acute  ophthalmia  is  similar  to  the  one  just  described.  It 
-is  very  communicable  and  most  probably  transmits  infection  by  a  specific 
organism. 

"Weeks^  was  the  first  to  describe  a  definite  micro-organism  causing 
this  disease.  The  Weeks  bacillus  is  short  and  has  rounded  ends.  It 
stains  Yeij  easily  with  methylene  blue.  It  is  intensely  contagious  and 
spreads  rapidly,  especially  in  schools.  Children  under  fifteen  years  are 
especially  susceptible. 

The  diplo-hacillus  of  Morax  was  described  by  him  in  June,  1896,  in 
the  Annal  de  FInstitut  Pasteur.  The  inflammation  is  frequently  due  to 
the  presence  of  the  diplo-bacilli.  The  inflammation  usually  begins  in  one 
eye  and  infects  the  other  a  few  days  later.  Its  course  may  be  either  chronic 
or  acute. 

Pneumococcus  Ophthalmia. 

This  disease  is  frequently  seen  in  new-born  children  in  which  the 
lachrymal  sac  suffers. 

Griff'ord^  described  an  epidemic  in  Omaha  where  several  distinct  out- 
breaks took  place  within  a  few  years. 

Veasey^  states  that  the  pneumococcus  is  the  most  frequent  cause  of 
ophthalmia  in  Philadelphia.  The  bacteriological  examinations  of  the  or- 
ganisms are  very  easily  made.  A  cover  glass  smeared  with  the  pus,  stains 
well  with  methylene  blue.  Under  the  microscope  there  are  diplococci, 
cocci,  and  chains  devoid  of  capsule. 

Infection  of  the  conjunctiva  sometimes  occurs.  This  is  frequently 
the  result  of  impetigo  contagiosa  of  the  face  or  scalp.  Infected  secre- 
tions transmitted  to  the  eye  by  the  fingers  usually  set  up  this  inflamma- 
tion. Little  girls  frequently  transmit  vaginal  discharges  on  their  fingers 
and  thus  cause  infection.  The  common  cocci  of  suppuration,  namely,  sta- 
phylococcus p3^ogenes  aureus,  albus,  and  citreus,  are  usually  found  in  this 
discharge. 


^  Archives  of  Oj>hthalmology,  1886,  No.  4,  p.  441. 

*  Griff ord :      Archives  of  Ophthalmology,  vol.  xxv,  1896,  p.  314. 

*Veasey:     Archives  of  Ophthalmology,  vol,  xxxviii,  1899,  p.  301. 


MKMBRANOUS    CONJUNCTIVITIS.  821 

Treatment. — Clean  the  eye  by  clipping  small  pledgets  of  absorbent  cot- 
ton into  lukewarm  water,  or  dip  the  cotton  into  a  2  per  cent,  solution 
of  borax.  A  medicine  dropper  can  be  filled  three  or  four  times  with  a 
solution  of: — 

a.  Formalin  ^  1  to  2000 

Sig.:      Wash  or  bathe  the  eye  with  this  formalin  solution  every  four  hours. 

Very  hot  water  applied  on  pledgets  of  sterilized  cheese-cloth  will  re- 
duce the  inflammation  of  the  lids.  In  other  cases,  cold  lead  and  opium 
wash  will  be  very  soothing  and  have  a  similar  effect.  We  can  prevent  the 
lids  from  sticking  together  by  applying  vaseline  at  night. 

Purulent  Ophthalmia  (Ophthalmia  Neonatorum). 

This  is  a  purulent  conjunctivitis  of  the  new-born  infant.  It  may  be 
seen  several  hours,  or  sometimes  appears  several  days,  after  birth.  The 
amount  of  pus  secreted  is  very  large.  When  the  lids  are  separated  pus 
will  be  liberated. 

Etiology. — It  is  usually  caused  by  an  infection  in  the  maternal  pas- 
sages containing  the  gonococcus  during  labor.  The  pneumococcus  has  also 
been  found  in  some  cases.  These  pathogenic  bacteria  are  carried  directly 
into  the  eye,  either  by  the  secretions  or  by  means  of  infected  sponges  or 
towels.  Bacteriology  has  proven  that  all  causes  excepting  distinct  germ 
infection  must  be  eradicated. 

Symptoms. — The  lids  appear  red  and  swollen.  The  upper  lid  fre- 
quently overhangs  the  lower  and  the  infant  is  unable  to  open  the  eyes. 
Stephenson  states  that  10  per  cent,  of  children  so  affected  remain  totally 
blind.  Of  446  cases  of  ophthalmia  occurring  in  the  practice  of  seven  phy- 
sicians quoted  by  Stephenson,  gonococci  was  found  in  72.83  per  cent.  In 
Stephenson's  own  cases,  out  of  45  affected,  30  showed  evidence  of  the  gono- 
cocci, or  66.5  per  cent. 

Preventive  Treatment. — The  Crede  method  is  now  universally  used. 
As  soon  as  the  infant  is  born  and  the  face  wiped  clean,  the  following  solu- 
tion is  dropped  into  the  eye: — 

It  Nitrate  of  silver  solution 2  per  cent. 

Sig. :  It  is  best  to  let  it  fall  from  a  medicine  dropper  on  the  eyeball.  A  slight 
inflammatory  reaction  is  occasionally  seen  and  if  treated  with  a  cold  solution  of 
formalin,  1  to  2000,  disappears  quickly. 

Membranous  Conjunctivitis   (Diphtheritic  Conjunctivitis). 

We  occasionally  see  membranous  patches  on  the  surface  of  the  con- 
junctiva.    This  membranous  deposit  is  sometimes  distinctly  diphtheritic, 


'  Formalin  is  a  45  per  cent,  solution  of  formaldehyde.     Formaldehyde  itself  is  a 
gas  and  a  strong  escharotic. 


822  DISEASES    OF    THE    EYE. 

a  culture  taken  showing  the  jDresence  of  the  Klebs-Loeffler  bacillus.  To 
differentiate  clinically  between  the"  diphtheritic  and  non-diphtheritic  type 
is  sometimes  impossible.  I  have  seen  membranous  conjunctivitis  at  the 
Willard  Parker  Hospital  in  which  the  disease  clinically  resembled  diph- 
theria and  still  the  Klebs-Loeffler  bacillus  was  absent.  In  one  case  seen 
by  me  the  streptococcus  alone  was  present.  The  clinical  history  of  the  case 
is  an  important  guide  in  the  diagnosis.  If  another  case  of  diphtheria  exists 
at  the  same  time  in  the  same  house,  the  question  of  transmission  should 
have  weight  in  making  the  diagnosis.  Every  case  of  membranous  conjunc- 
tivitis requires  a  careful  inspection  of  the  fauces.  If  croupous  laryngitis  is 
present,  then  a  greater  probability  of  diphtheria  is  warranted. 

Symptoms. — A  grayish-yellow  patch  can  be  seen  on  the  conjunctiva. 
The  lids  are  very  tender  and  swollen.  They  feel  hard  and  thick  on  palpa- 
tion, and  cannot  be  everted.  Ulceration  or  sphacelation  of  the  cornea 
usually  follows.  The  same  systemic  disturbances  may  be  noted  as  are  found 
in  diphtheria  affecting  the  throat.  There  is  usually  fever,  glandular  en- 
largement, loss  of  appetite,  general  prostration,  and  cardiac  disturbances, 
as  has  been  described  in  the  chapter  on  "Diphtheria.^^ 

Prog"nosis. — A  very  guarded  prognosis  is  necessary,  as  the  outcome  of 
the  case  depends  upon  the  care  bestowed  and  the  time  when  the  case  was 
first  seen.  If  the  disease  has  been  established  a  long  time,  a  greater  de- 
structive tendency  must  be  presumed  than  if  the  case  was  seen  when  it  first 
originated. 

Treatment. — First  isolate.  The  communicable  nature  of  this  disease 
must  be  remembered.  The  family  and  friends  should  be  warned  of  the 
danger. 

Local  Treatment. — If  the  eyes  are  thick  and  swollen,  an  ice-bag  or 
ice-cold  pledgets  of  cotton  soaked  in  bichloride,  1  to  2000,  should  be  ap- 
plied. They  should  be  renewed  every  five  to  ten  minutes  night  and  day, 
to  produce  a  good  result.  In  other  cases  warm,  moist  applications  will 
alleviate  pain  and  also  reduce  inflammation. 

Specific  Treatment. — Diphtheria  is  diphtheria  whether  it  is  in  the  eye 
or  in  the  throat,  hence  an  injection  of  5000  units  of  antitoxin  should  be 
given  regardless  of  the  age  of  the  child.  The  same  internal  treatjjient 
which  is  described  in  the  chapter  on  "Diphtheria'^  is  recommended  if  we 
desire  successful  results  in  these  cases. 

Granular  Ophthalmia  (Trachoma). 

The  characteristic  feature  lies  in  the  development  on  the  palpebral 
conjunctiva  of  the  so-called  "sago  grains.'' 

Granular  lids  must  be  carefully  considered  owing  to  their  disastrous 
tendency. 


GRAM L'LAR    (JIM ITIlAl.AllA. 


823 


The  following  table,  slightly  modified  from  Stephenson  ('"Epidemic 
Ophthalmia/'  1895)  gives  the  dilferential  diagnosis  between  folliculosis 
of  the  conjunctiva  and  trachoma: — 

Table  No.  80. 


FALSE  OR  FOLLICULAR  GRANULATION. 
1.  Oval  or  roundish  transparent 
bodies  the  diameter  of  which  never  ex- 
ceeds from  1  millimeter  to  1  Va  milli- 
meters. Of  a  faint  yellowish  hue,  ar- 
rangeil  in  rows  parallel  to  the  lid  border, 
and  discrete.  Most  marked  in  inferior 
retrotcirsal  fold. 


2.  Little  or  no  change  in  the  structure 
of  the  conjunctiva. 


TRACHOMA. 

1.  Round,  opaque,  ill-defined  bodies,  of 
giuyish-white  color  and  extreme  friabil- 
ity. Firmly  and  deeply  embedded,  in  the 
conjunctiva,  their  diameter  not  in- 
frequently reaches  2  millimeters  or  more. 
Tendency  to  become  coulluent  and  form 
masses  or  areas  of  trachomatous  ma- 
terial. Most  numerous  and  larger  in 
upper  retrotarsal  fold. 

2.  Structural  changes  always  present. 


3.  Papillary  hyi^ertrophy  of  upper  lid 
slight. 

4.  Tarsus  never  implicated. 

5.  Disappear  spontaneously  generally 
and  leave  no  scar. 


3.  jMarked  hypertrophied  papillae  of 
upper  lid  generally  present. 

4.  Tarsus  often  involved. 

5.  Spontaneous  cure  may  occur,  but 
only  by  cicatrization,  which  may  be 
slight  or  extensive  according  to  the 
amount  of  tissue  involved. 


6.  No  ptosis. 


6.  Ptosis    nearly    always    present    in 
some  degree. 


7.  No  pannus. 


7.  Keratitis  in  the  form  of  pannus  or 
ulcer  in  about  25  per  cent,  of  the  cases. 


8.  No    trichiasis,    entropion,    or   cica-  8.  Fi'equently  leads  to  trichiasis,  en- 

tricial  contraction  of  the  cul-de-sac.  tropion,  or  shrinking  of  the  cul-de-sac. 


9.  Most  frequent  in  persons  under  20 
years. 

10.  Non-contagious. 


9,  May  occur  at  any  age. 


10.  Conditionally  contagious. 


This  disease  may  frequently  assume  an  epidemic  nature.  Dur- 
ing the  last  two  years  hundreds  of  cases  have  suddenly  appeared  in  our 
city.  The  ease  with  which  all  infectious  diseases  spread  in  the  congested 
portions  of  our  city  applies  to  trachoma.  For  this  reason  school-children 
and  inmates  of  institutions  and  hospitals  should  have  the  eyes  carefully 
inspected  on  admission  to  exclude  trachoma.  In  our  country  the  native 
American  Indian  suffers  from  this  disease,  so  do  the  Irish,  Polish,  Italians^ 


824 


DISEASES    OF    THE    EYE. 


and  the  Teutonic  races.  It  is  therefore  quite  probable  that  this  disease  is 
spread  more  or  less  among  all  races.  One  race  is  exempt;,  namely,  the 
negro. 

Treatment. — Of  all  methods,  expression  is  the  method  generally  used. 
The  morbid  tissue  is  thereby  dislodged  and  removed.  Actual  cauterization, 
galvano-cautery,  or  the  solid  nitrate  of  silver  stick  is  mentioned  by  some, 
but  should  be  used  only  by  those  familiar  with  the  eye.  The  advice  that  I 
give  in  my  office  to  patients  suffering  with  trachoma,  is  to  recommend  them 
to  an  eye  specialist. 


Fig.  280. — Trachoma,  Showing  Round,  Opaque  Bodies  in  Upper  and 
Lower  Lids.  "Sago  grain"  type.  From  a  photograph — frequent  type  seen 
in  children.     (Original.) 


Blepharitis. 

This  disease  is  characterized  by  a  sub-acute  or  chronic  inflammation 
along  the  margin  of  the  lids. 

Two  classes  of  cases  might  be  noted.  First,  those  in  which  slight 
crusts  appear  on  the  edges  which,  when  cleared  off,  show  no  loss  of  sub- 
stance; simply  reddened  margin.  This  would  include  the  cases  of  mar- 
ginal eczema,  so  called.  Second,  those  cases  which,  when  cleared  of  crusts, 
show  ulceration. 

The  first  class  of  cases  seek  treatment  for  cosmetic  results.  There  is 
no  pain,  only  a  slight  discomfort  exists.  These  cases  are  all  aggravated 
by  exposure  to>  dust,  wind,  heat,  or  long  spells  of  work. 

The  second  class  of  cases  is  more  serious.  At  first  they  present  a  dusky 
margin  and  gluing  together  of  eyelashes,  due  to  excessive  secretion,  which 


HORDEOLUM. 


825 


gradually  progresses.  Beneath  the  crusts  ulcers  form.  Excoriations  and 
pustules  about  the  hair  follicles  interfere  with  the  growth,  so  that  the 
lashes  fall  out  or  become  stunted.  The  vascularity  continues,  increasing  the 
thickness  of  the  lids  with  new  connective  tissue.  Tlie  gradual  contraction 
of  this  new  scar  tissue  leads  to  evcrsion  of  the  lids  with  resulting  epiphora, 
or  overflow  of  tears,  presenting  a  disagreeable,  raw-looking  surface. 

Treatment. — Generally  speaking,  the  treatment  consists  of  removing 
the  crusts  or  scabs  l)y  any  warm  alkaline  lotion,  such  as  bicarbonate  of  soda, 
or  biboratc  of  soda,  10  to  20  grains;  aqua3,  1  ounce.  Massage  of  the  lids 
with  red  or  yellow  oxide  or  white  precipitate,  2  to  8  grains ;  vaseline,  1  ounce, 
should  follow. 

A  mild  ointment  should 
be  used — a  strong  one  in- 
creases the  irritation.  All  re- 
fractive errors  must  be  cor- 
rected. Epilation  of  the 
lashes  sometimes  promotes  a 
cure  when  commenced  in  the 
early  stages  of  the  disease. 
The  general  condition  of  the 
patient  must  be  looked  after, 
and  iron,  arsenic,  codliver- 
oil,  or  similar  tonics  and  hy- 
gienic treatment  as  indicated 
should  be  prescribed. 

Hordeolum,  or  Stye. 

This  disease  is  character- 
ized by  an  inflammation  of 
the  connective  tissue  about  a 
hair  follicle  along  the  lid 
margin.  A  hard,  circum- 
scribed, inflammatory  nodule  forms,  which  may  suppurate.  Occasionally,  it 
remains  as  a  hard  lump,  and  still  in  other  cases  the  lid  becomes  swollen  and 
oedematous.  A  close  examination,  however,  will  show  the  inflammatory  spot, 
which  as  soon  as  it  appears  yellowish  should  be  incised  and  the  pus  evacu- 
ated. 

Treatment. — The  general  treatment  consists  in  hot  applications  to 
favor  resolution.  To  prevent  successive  crops,  the  massaging  of  the  lids 
with  an  ointment  of  hydrarg.  ox.  flav.,  ^/^  to  2  grains ;  vaseline,  2  drachms, 
has  an  excellent  effect.  The  infection  from  the  pus  may  be  prevented  by 
the  use  of  argyrol  in  a  5  per  cent,  solution,  one  drop  two  or  three  times 
daily. 


Fig.    281.— Method  of  Everting  Eyelid. 
(After  Davis  and  Douglass.) 


826  DISEASES    OF    THE    EYE. 

These  successive  styes  show  some  disease  of  the  lid  margin^  as  blepha- 
ritis, some  derangement  of  the  general  system,  or  eye-strain,  especially  in 
hypermetropia. 

Phlyctei^iilab  Conjunctivitis. 

This  affection  is  one  of  childhood  and  is  seen  in  malnutrition  after 
the  acute  exanthemata;   also  in  marasmic  or  scrofulous  children. 

Small  elevated  spots,  papules,  or  pustules  the  size  of  a  mustard  seed 
are  found  in  this  condition.  When  the  epithelial  covering  is  shed  they 
become  superficial  ulcers.  They  are  either  single  or  multiple,  and  appear 
as  pinkish,  yellowish,  or  grayish  spots.  There  is  very  often  a  great  dread  of 
light — photophobia — which  leads  to  spasms  of  the  lids — ^blepharospasm. 
There  are  also  at  times  pain,  burning  sensation,  and  lachrymation. 

Treatment. — Local  treatment  consists  of  bathing  with  a  saturated  solu- 
tion of  boric  acid.  If  any  excoriation  exists  at  outer  canthus,  touching  it 
with  nitrate  of  silver  generally  effects  a  cure. 

If  the  symptoms  show  that  the  condition  is  subacute  or  chronic  then 
stimulating  applications  are  required,   as: — 

IJ  Hydrarg.  ox  flav 4  to  8  grains 

Vaseline   1  ounce 

M.  and  apply  three  times  a  day. 

I  have  had  excellent  results  by  touching  the  affected  parts  lightly  with 
a  solid  stick  of  alum  or  copper. 

If  there  is  much  corneal  involvement: — 

5  Atropin   sulph V2  grain 

Aq.   dest 2  drachms 

Sig. :     One  drop  in  the  eye  once  or  twice  daily  may  have  to  be  used. 

For  the  blepharospasm,  a  force  I  opening  of  the  lids,  an  occasional  drop 
of  a  2  per  cent,  solution  of  cocaine,  or  a  sudden  plunging  of  the  head  in 
cold  water  will  relieve  the  condition. 

General  Treatment. — This  consists  in  the  hygienic  care  of  the  child 
and  tonic  treatment.  The  eyes  should  be  kept  clean  and  open,  dark  glasses 
should  be  worn  if  necessary.  No  dark  room,  bandages,  or  eye  shields  should 
be  allowed.  The  bowels  should  be  regulated.  The  diet  should  be  looked 
into.  All  sweets  interdicted,  meat  given  occasionally,  and  milk  foods  or- 
dered. Give  plenty  of  fresh  air,  outdoor  exercise,  and  bathing.  Tonics, 
such  as  codliver-oil,  syr.  ferri  iodide,  str}^chnine,  etc.,  should  be  given. 


CHAPTER  III. 

DISEASES  OF  THE  SKIN. 

Eczema. 

This  eruptive  disease  is  very  frequently  seen  in  infants  as  well  as  in 
older  children. 

Etiology. — Irritation,  be  it  an  irritant  soap  or  an  irritant  discharge, 
can  give  rise  to  eczema.  Eczema  is  frequently  an  external  manifestation 
of  toxic  conditions.  The  frequency  with  which  eczema  is  seen  in  children 
with  dyspeptic  conditions  certainly  invites  consideration.  Children  having 
rickets  are  frequent  sufferers  with  eczema.  Some'  authors  believe  that 
pathogenic  hacioria  can  enter  the  shin  and  set  up  eczema.  While  this  ap- 
pears plausible,  it  remains  to  be  proven.  It  is  found  associated  with  de- 
ficient elimination  from  the  skin  in  the  unclean,  in  dyspeptic  conditions 
when  the  stomach  and  bowels  are  not  properly  functionating,  and  also 
when  the  kidneys  do  not  properly  act.  I  have  frequently  seen  children 
with  a  facial  eczema  which  appeared  when  oatmeal  was  given  and  disap- 
peared when  the  same  was  stopped.  Eczema  may  be  due  to  reflex  irrita- 
tion. Holt  says  that  cases  which  accompany  dentition  and  those  due  to 
genital  irritation  can  be  called  reflex. 

This  disease  can  be  either  localized  (regional),  as  when  it  is  confined 
to  the  face  or  between  the  thighs,  or  it  can  be  general  or  universal. 

Symptoms. — There  is  always  an' intense  itching  or  burning  with  the 
appearance  of  the  eczema.  On  the  cheeks  it  usually  begins  with  "small 
red  papules,  later  these  coalesce  and  there  is  a  moist  red  surface,  exuding 
serum  or  sero-pus."  Children  scratch  and  thus  usually  produce  bloody 
streaks.  The  crusts  have  a  yellowish-brown  appearance.  There  is  a  red- 
ness, thickening,  and  always  scaliness  of  the  skin.  The  glands  in  the  im- 
mediate neighborhood  are  usually  swollen ;  they  rarely  lead  to  suppuration. 

Eczema  frequently  spreads  from  the  face  to  the  forehead  and  the  neck, 
and  I  have  seen  it  involve  the  whole  head. 

Inrant  G.  S.,  seven  months  old,  was  nursed  about  six  weeks  at  his  mother's 
breast.  He  was  then  fed  on  top  milk  and  barley  water.  As  this  disagreed  he  was 
given  barley  water.  He  then  had  dyspeptic,  greenish  stools,  and  the  feeding  was 
changed  to  milk  and  rice  water,  which  seemed  to  agree  qiiite  well.  He  gained  steadily 
one-half  pound  every  week  for  the  next  three  months.  He  was  at  the  seashore  all 
summer  and  had  no  evidence  of  summer  complaint.  \^nien  seven  months  old  he 
was  slightly  constipated  and  with  it  had  dyspeptic  fermentation.  His  appetite  was 
poor.     It  was  necessary  to  stimulate  the  bowels  to  produce  proper  evacuations. 

(827) 


828  DISEASES  OF  THE  SKIN. 

Teething  appeared  at  about  the  eighth  month.  At  the  same  time  the  child  had  a 
severe  attack  of  influenza  of  the  gastric  type,  with  high  fever,  anorexia,  and  gastro- 
intestinal atony.  At  this  time  a  scaly  and  papular  eczema  appeared  on  one  cheek 
and  rapidly  spread  to  both  cheeks.  With  the  application  of  a  bland  ointment  con- 
sisting of  zinc  oxide  and  vaseline  it  disappeared.  One  week  later  I  again  saw  this 
child  with  a  relapse  of  high  fever  and  dyspeptic  symptoms,  and  a  severe  eczema 
covering  an  area  larger  than  before.  It  was  very  red  and  angry  looking  and  weep- 
ing in  character.  A  gauze  mask  saturated  with  calamine  and  zinc  lotion  (3  per  cent.) 
produced  a  marked  improvement,  besides  relieving  the  itching.  Internally  I  gave  rhu- 
barb and  soda  tablets  in  addition  to  cutting  down  the  quantity  of  milk  one-half 
of  the  previous  strength.  After  three  weeks  of  this  form  of  treatment  I  was  able  to 
return  to  the  former  full  milk  feeding  and  the  eczema  did  not  return. 

CALAMINE  LOTION. 

IJ  Pulv.  calamini   2  parts 

Pulv.  zinci  ox 2  parts 

Glycerini 1  part 

Aq.  calcis   30  parts 

Treatment. — Another  cooling  and  antipyretic  lotion  that  has  served  me 
very  well  is  the  following: — 

IJ  Phenol  20  drops 

Zinc  oxid 3  drachms 

Calamine 2  drachms 

Glycerine ■ 4  drachms 

Liq.  plumbi  subacet.  dil 1  ounce 

Lime  water q.  s.  ad  6  ounces 

The  following  are  suggested: — • 

IJ  Zinc  oxide 2  drachms 

Amyl    '. 2  drachms 

Naphthalan   1  ounce 

Apply  "at  night.     (Dr.  John  Fordyce.) 

unna's  soft  zinc  paste. 
U  01.  lini, 

Aq.  calcis, 

Zinci  ox., 

Cretse of  each,  equal  parts. 

Bland,  unirritating  applications,  such  as  rice  powder,  zinc  oxide,  stearate 
of  zinc,  talcum,  or  cornstarch,  are  very  cooling,  and  seem  to  act  by  absorbing 
the  heat  and  moisture  if  any  be  present. 

Bathing  in  Eczema. — I  have  frequently  found  an  apparently  cured  case 
of  eczema  break  out  anew  Avith  a  red  blush  and  eczematous  patches  after 
one  ordinary  cleansing  bath  was  given.  In  the  acute  stages  water  should 
be  omitted.  Applications  of  a  5  or  10  per  cent,  calamine  and  zinc  salve 
or  lotion,  as  described  in  the  clinical  case  above  given,  are  very  beneficial. 


ECZEMA.  829 

Soap  should  never  be  used.  When  hard  crusts  cover  the  surface  of  the 
skin  and  cannot  be  softened  by  the  ordinary  application  of  salves,  the  fol- 
lowing treatment  should  be  instituted :  A  bland  bath  consisting  of  one 
pound  of  oatmeal  in  a  cheese-cloth  bag,  thoroughly  soaked  in  hot  water  for 
at  least  one-half  hour,  and  enough  water  added  to  bathe  the  eczematous 
parts.  After  thorough  soaking  in  this  oatmeal  bath  the  calamine  and  zinc 
or  a  2  per  cent,  boric  acid  and  vaseline  ointment  should  be  applied.  One 
bath  only  should  he  given.  The  salve  should  be  applied  three  times  a  day 
for  at  least  one  week.  Irritating  ointments,  or  those  containing  tar,  should 
be  avoided  in  the  acute  condition. 

Eczema  Eubrum. 

The  eczematous  blush  affecting  the  face  may  be  mistaken  for  erysip- 
elas. Erysipelas  usually  occupies  a  smaller  area,  generally  on  the  bridge  of 
the  nose.  High  fever  usually  accompanies  erysipelas;  this  will  easily  dif- 
ferentiate the  condition.  The  treatment  is  the  same  as  that  outlined  in 
the  article  on  "Eczema.'' 

SALICYLIC-SULPHUB    PASTE. 

IJ  Ac.  salicyl 1  part 

Sulph.  depur 5  parts 

Petrolati    25  parts 

Zinci  oxid 10  parts 

Amyli    10  parts 

ICHTHYOL    OINTMENT. 

IJ  Ammon.  sulph.  ichthyolat 5  parts 

Aq.  dest 5  parts 

Adeps  benzoat 15  parts 

Adeps  lanae 25  parts 

Crusta  Lacta. 

To  soften  the  milk  crusts  which  form  on  the  scalp  of  infants,  applica- 
tions of  the  following  will  loosen  the  crusts,  after  which  they  may  gently 
be  combed  away: — 

IJ  Olive  oil   %  ounce 

Castor  oil    %  ounce 

Salicylic   acid    4     per  cent. 

Eczema  Intertrigo. 

In  fat  children  where  two  opposing  surfaces  of  skin  are  in  contact, 
such  as  between  the  thighs  or  toes  or  in  the  armpits,  a  red  form  of  inflam- 
mation frequently  ensues.  It  is  sometimes  accompanied  by  a  thin,  foul- 
smelling  discharge,  which  may  be  serous,  but  very  rarely  is  purulent.  This 
condition  is  more  apt  to  be  noticed  in  the  unclean. 


830  DISEASES  OF  THE  SKIN. 

Treatment. — Eemove  the  cause  by  separating  the  parts.  Sprinkle 
freely  with  talcum,  zinc  oxide,  lycopodium,  fullers'  earth,  or  any  good 
infant's  powder.  In  severe  cases  separate  the  parts  by  placing  a  sterile  pad 
of  cheese-cloth  on  both  sides  of  which  zinc  salve  is  smeared.  All  warm 
clothing  should  be  avoided.  When  severe  excoriation  results  from  dis- 
charges and  is  not  checked  by  the  application  of  bland  salves,  then  cool 
lead  and  opium  wash  applied  for  a  day  or  more  is  soothing  and  will  reduce 
the  inflammation. 

When  infected  conditions  occur,  apply: — 

IJ  Hydrarg.  ammoniate   10  grains 

Lassar's  paste  1  ounce 

Eryti-tema. 

Local  irritation  such  as  might  be  caused  by  a  mustard  plaster  or  the 
friction  of  a  dress,  producing  a  "chafe,"  or  irritating  secretions,  such  as 
a  purulent  ophthalmia  or  acrid  discharge  from  the  nose,  produces  this  ery- 
thema. It  is  frequently  seen  in  infants  on  the  buttocks  from  lack  of  clean- 
liness. When  seen  on  the  buttocks  it  may  be  mistaken  for  syphilis.  Ery- 
thema is  easily  differentiated  from  syphilis  by  the  absence  of  snuffling  of 
the  nose,  of  the  ham-colored  eruption,  and  of  the  inelastic,  cracked  appear- 
ance of  the  soles  and  palms. 

Urticaria  (Hives;  ISTettle  Eash). 

This  inflammatory  condition  of  the  skin  appears  very  suddenly.  No 
special  portion  of  the  bod)'-  is  exempt;  thus,  it  may  occur  on  the  face, 
abdomen,  or  extremities.  It  consists  of  irregular-shaped  blotches  called 
wheals.  When  these  spots  disappear  they  leave  no  trace  behind.  There 
are  several  varieties  of  urticaria. 

Urticaria  annularis  occurs  in  rings. 

Urticaria  figurata  occurs  in  spirals. 

Urticaria  vesiculosa  has  vesicles  on  the  summit  of  the  wheal. 

Urticaria  bullosa  is  a  bullous  development  on  summit  of  wheal. 

Urticaria  papulosa  is  a  wheal  combined  with  a  papule. 

Urticaria,  tuherosa  are  giant  wheals. 

Urticaria  hcemorrhagica  is  a  combination  of  urticaria  with  purpura. 

Urticaria  pigmentosa  is  a  pigmentation  following  the  wheals. 

The  form  most  frequently  met  with  in  children  is  likely  due  to  (a) 
ptomaine  poisoning;  (h)  the  result  of  some  toxin  in  the  system. 

Causes. — Shell-fish,  strawberries,  and  frequently  cereals  seem  to  be  the 
cause  of  urticaria  in  some  children.  There  is  usually  some  gastric  or  gastro- 
intestinal disturbance  at  the  time  of  the  appearance  of  this  rash.  There 
seems  to  be  a  peculiar  idiosyncrasy  in  some  children  to  quinine  and  to 


HERPES  ZOSTER.  831 

other  drugs  which  will  bring  out  an  attack  of  urticaria.  A  great  many 
children  have  severe  urticaria  after  an  injection  of  antitoxin.  (Read 
article  on  "Antitoxin  Rashes.")  Insect  bites  will  sometimes  cause  this 
condition. 

Symptoms. — There  is  severe  itching,  and  scratching  will  frequently 
develop  a  new  rash.  Fever  sometimes  accompanies  this  condition.  Urti- 
caria once  seen  is  very  easily  recognized  and  is  not  hard  to  differentiate. 

The  prognosis  is  usually  good.  We  must  remember  that  children  prone 
to  idiosyncrasies  will  have  urticaria  quite  frequently;  thus,  it  will  depend 
on  the  diet  as  to  whether  or  no  the  rash  remains  away. 

Treatment. — ^The  first  thing  to  do  is  to  cleanse  the  gastro-intestinal 
tract  with  one  or  two  teaspoonfuls  of  castor-oil,  followed  with  1  drachm  of 
rhubarb  and  soda  every  three  hours  until  the  stools  become  loose,  and  the 
condition  is  improved. 

Locally. — The  severe  itching  can  best  be  allayed  by  making  a  paste 
of  bicarbonate  of  soda  and  cold  water.  Rub  this  paste  into  the  hives.  A 
cool  tub  bath,  containing  several  ounces  of  bicarbonate  of  soda,  will  fre- 
quently relieve  the  itching.  Evaporating  lotions,  such  as  lead  and  opium 
wash  or  a  weak  solution  of  vinegar  and  water,  are  soothing  to  some  cases. 
In  other  cases  the  following  will  give  relief : — 

R  Resorcin    1  part 

Menthol    1  part 

Phenol     1  part 

Alcohol 200  parts 

M.     Apply  with  cotton. 

Large  quantities  of  water  should  be  given  for  thirst.  It  will  also  aid 
in  eliminating  toxins  through  the  kidneys. 

Herpes  Zoster  (Shingles). 

"This  is  an  acute  inflammation  consisting  of  a  group  of  vesicles.  It  is 
mostly  seen  over  a  surface  of  skin  corresponding  to  a  definite  nerve  tract. 
It  is  accompanied  by  neuralgic  pain." 

Symptoms. — As  a  rule,  there  is  a  broad  band  of  vesicles  corresponding 
to  the  affected  area,  usually  following  a  nerve  tract  along  the  limbs  or  along 
the  borders  of  the  ribs.  It  develops  very  rapidly  and  frequently  resembles 
an  erythema.  The  crop  of  vesicles  is  frequently  so  thick  that  they  almost 
touch  one  another. 

Prognosis. — As  this  is  a  self-limited  disease,  the  prognosis  is  good, 
although  neuralgic  pains  may  persist  for  some  time  after  the  disappearance 
of  the  eruption. 

Treatment. — Avoid  irritant  salves  and  use  cooling  dusting  powders, 
such  as  bismuth,  cornstarch,  wheat  flour,  or  powdered  zinc  oxide.     The 


832  DISEASES  OF  THE  SKIN. 

affected  part  should  be  covered  with  linen  or  gauze,  not  flannel  or  wool.  To 
allay  intense  itching  or  inflammation  use  calamine  and  zinc  lotion  (see 
chapter  on  "Eczema"). 

Chloasma  (Tinea  Yersicolor;  Liver  Spots). 

This  is  a  very  mild  form  of  eruption  in  which  brown  patches  of  skin 
are  seen.    It  is  caused  by  the  invasion  of  a  fungus. 

Treatment. — The  application  of  white  precipitate  ointment  or  1  per 
cent,  bichloride  in  alcohol  has  served  me  very  well  in  removing  the  same. 

Psoriasis. 

This  is  a  chronic  inflammatory  disease  affecting  the  extensor  sur- 
faces.   It  consists  of  a  red,  scaly  patch  in  which  white,  silvery  scales  abound. 

Etiology. — There  is  no  specific  factor,  as  it  is  found  in  both  the  rich 
and  poor,  although  it  frequently  follows  malnutrition  of  the  body  such 
as  we  see  after  the  acute  infectious  diseases.  This  condition  also  fre- 
quently affects  children  of  gouty  parentage. 

Symptoms. — ^The  extensor  surfaces  are  usually  affected;  hence  the  dis- 
ease will  be  found  on  the  extensor  sides  of  the  arms  and  legs.  The  sym- 
metrical arrangement  of  this  eruption  on  both  sides  of  the  body  is  a  char- 
acteristic condition. 

Prognosis. — This  should  always  be  cautiously  given.  As  the  disease 
has  a  chronic  tendency,  it  may  remain  for  years  unless  actively  treated. 

Treatment. — Locally : — 

IJ  Chrysarobin    2  to  10  per  cent. 

Petrolatum    1  ounce 

or  as  a  varnish 

IJ  Chrysarobin    2  to  10  per  cent. 

Liquid  gutta  percba  or  traumaticine   1  ounce 

B  Salicylic  acid  .T 4  drachms 

Chrysarobin  2  scruples 

Painted  on  daily,  until  reaction  follows. 

Whenever  treatment  is  given,  it  must  be  continued  until  every  spot  has 
disappeared ;  otherwise  the  condition  will  relapse. 

The  primary  infectious  agent  is  the  streptococcus;  later  we  have  the 
staphylococcus. 

Systemic  Treatment. — No  one  must  expect  to  cure  this  disease  unless 
the  emunctories  are  properly  looked  after.  We  must  keep  the  bowels  loose, 
and  the  kidneys  active.  The  dairy  products  should  be  permitted ;  also  meat, 
vegetables,  and  fruit. 


PEDICULOSIS.  833 

Eestorative  treatment  such  as  codliver-oil,  iron,  and  arsenic  should  be 
given  liberally.  In  this  disease  arsenic  proves  itself  of  great  value.  Ar- 
senic need  not  be  feared  and  can  be  given  to  children  in  very  large  doses. 
Fowler's  solution,  in  3-  to  10-  drop  doses  three  times  a  day,  is  usually 
sufficient. 

Impetigo. 

This  infectious  and  contagious  disease  is  characterized  by  an  eruption 
which  may  appear  on  any  part  of  the  body.  It  is  most  frequently  seen  on 
the  exposed  parts,  usually  on  the  face  and  hands. 

Symptoms. — There  may  or  may  not  be  fever  at  the  onset  of  the  erup- 
tion. The  eruption  usually  commences  on  the  face  and  hands.  It  is  easily 
communicated. 

Treatment. — ^A  tub-bath  consisting  of  kali  sulphur  (one  ounce),  dis- 
solved in  a  porcelain  or  wooden  tub  full  of  water.  The  temperature  of  this 
bath  should  be  about  100°  F.,  and  the  duration  of  the  bath  about  five 
minutes.  This  bath  should  be  repeated  every  night,  before  retiring,  for  one 
week.  If  the  sulphur  bath  cannot  be  used,  then  apply  a  10  per  cent, 
ammoniate  mercury  ointment  rubbed  up  with  zinc  oxide. 

The  following  lotion  may  be  applied  several  times  a  day : — 

IJ  Zinc  sulphate 3.5  parts 

Copper  sulphate   1      part 

Aqua    100      parts 

Pediculosis. 

Among  the  neglected  or  unclean  we  frequently  see  this  condition.  It  is 
caused  by  the  invasion  of  a  parasite,  the  pediculus  capitis.  There  is  usually 
an  eczematous  condition  and  the  adjacent  glands  are  swollen.  The  habitat 
of  the  pediculus  is  in  the  hair,  but  it  causes  eczematous  patches  by  irritation. 

Pediculosis  is  often  complicated  with  impetigo.  It  spreads  to  the  face 
and  makes  a  picture  of  impetigo.  The  infection  is  primarily  streptococcus, 
secondarily  staphylococcus. 

Treatment. — First,  remove  the  hair,  if  at  all  possible;  if  not,  saturate 
the  hair  with  petroleum,  but  avoid  the  scalp.  This  should  be  left  on  five 
or  six  hours,  after  which  the  scalp  and  hair  should  be  saturated  with  equal 
parts  of  ether  and  tincture  of  delphin  to  loosen  the  nits,  which  can  then  be 
removed  with  a  fine  comb.  The  hair  should  then  be  thoroughly  washed  with 
soap  and  water. 

Miliaria  Papulosa  (Lichen  Tropicus;  Prickly  Heat). 

This  variety  of  skin  disease  is  frequently  seen  in  summer.  It  consists 
of  bright-red  papules  on  the  summits  of  which  there  are  very  tiny  vesicles ; 
at  times  pustules  may  also  be  seen.    The  eruption  is  usually  confined  to 

63 


834      •  DISEASES  OF  THE  SKIN. 

those  parts  which  are  warmly  clad,  so  that  the  abdomen,  chest,  and  the 
extremities  are  most  frequently  covered.  Eczema  frequently  follows  this 
condition,  and  if  severe  scratching  takes  place,  local  infection  ending  ia 
furunculosis  may  occur.  The  other  parts  of  the  body  which  do  not  have 
the  eruption  usually  show  extensive  perspiration.  This  eruption  comes 
and  goes  very  quickly.  It  is  frequently  mistaken  for  scarlet  fever.  The 
absence  of  fever,  the  appearance  of  the  tongue  and  throat,  and  the  absence 
of  the  prodromal  symptoms  will  easily  differentiate  this  condition. 

Treatment. — Ehubarb  and  soda  or  a  dose  of  calomel  at  the  beginning. 
If  the  kidneys  are  inactive,  then  10  to  20  drops  of  sweet  spirits  of  niter 
should  be  given,  and  repeated  two  or  three  times  a  day.  For  the  intense 
itching'  the  application  of  a  paste  consisting  of  bicarbonate  of  soda  and 
water  will  stop  the  itching.  The  body  should  be  made  comfortable  by 
removing  all  warm  clothing.  A  tepid  alkaline  bath,  temperature  70°  F. — ; 
a  bath  to  which  several  ounces  of  bicarbonate  of  soda  have  been  added — 
is  very  grateful  and  will  give  quick  relief.  After  the  bath,  dry  the  body 
thoroughly  and  dust  cornstarch  or  wheat  flour  with  talcum  or  zinc  oxide, 
and  let  the  child  sleep  with  as  little  clothing  on  as  possible.  If  im- 
provement does  not  follow  within  twenty-four  hours,  then  the  application 
of  the  following  salve  will  relieve  itching  and  reduce  the  inflammation : — 

I^  Zinc  oxide 1  draclim 

Calamine    1  drachm 

Cold  cream 1  ounce 

M.    Apply  three  times  a  day. 

Miliaria  Eubra  (Strophulus  Infantum;  Eed  Gum). 

This  rash  is  the  result  of  an  irritation  due  to  perspiration.  It  con- 
sists of  red  papules,  sometimes  having  tiny  vesicles.  It  is  usually  seen 
on  the  cheeks  of  an  infant  and  always  upon  the  side  on  which  the  infant 
sleeps. 

The  treatment  is  the  same  as  that  given  in  the  article  on  "Miliaria 
Papulosa." 

SUDAMINA. 

Sudamina  are  small,  pearly  bodies  occurring  during  fever  or  exhausting 
diseases.  They  are  usually  seen  over  the  sweat  ducts.  They  are  easily 
absorbed  and  fresh  crops  take  the  place  of  these  tiny  vesicles. 

Lentigo  (Freckles).  i 

This  is  a  very  common  affection  of  the  skin.  It  is  usually  seen  in 
children  over  5  years  of  age,  and  most  especially  in  those  having  blonde 
or  red  hair.  The  skin  is  certainly  more  sensitive  to  sunlight  in  such  cases, 
and  successive  crops  of  freckles  frequently  appear  after  exposure  to  the 
light. 


FURUNCLE.  835 

The  treatment  consists  in  protecting  the  skin  against  exposure  to  the 
light.  The  freckles  can  be  removed  by  a  mild  form  of  counter-irritation, 
such  as  the  application  of  a  1  per  cent,  solution  of  bichloride  of  mercury. 
Apply  on  cotton  to  the  affected  area  for  three  or  four  successive  hours.  This 
form  of  counter-irritation  destroys  the  skin,  causing  it  to  desquamate.  The 
new  epidermis  which  appears  is  free  from  this  pigment. 

Seborehgea. 

This  is  a  very  common  condition  of  thick,  dry,  crusty  formation  which 
occurs  on  the  head  of  infants.  It  most  frequently  involves  that  region 
surrounding  the  anterior  fontanel.  There  are  two  varieties:  (a)  sebor- 
rhoea  oleosa;  (&)  seborrhoea  sicca.  Some  authors  state  that  if  the  vernix 
caseosa  in  the  new-born  is  allowed  to  continue,  it  passes  into  a  seborrhoea 
and  may  eventually  become  an  eczema.  When  carefully  examined,  sebor- 
rhoea will  be  found  to  consist  of  epithelial  cells,  fat,  and  chiefly  dirt.  There 
are  no  inflammatory  symptoms.  When  the  scales  are  removed  the  skin  is 
usually  found  normal. 

Treatment. — The  following  is  recommended: — 

!R   Salicylic  acid 15  grains 

Vaselin    1  ounce 

M.  Rub  the  scalp  thoroughly  several  times  a  day  and  leave  on  overnight. 
Wash  scalp  with  soap  and  warm  water  the  following  morning.  If  necessary  repeat 
several  evenings  and  wash  in  the  morning  as  above  directed.  Sulphur  soap  is  useful 
in  this  condition.  The  officinal  ointment  of  sulphur  can  be  rubbed  into  the  scalp  if 
this  condition  recurs. 

Furuncle  (Boil). 

This  inflammatory  condition  occurs  around  a  hair  follicle  or  a  gland 
of  the  skin.  It  is  most  likely  caused  by  scratching,  during  which  process 
there  is  an  infection  of  the  follicle  with  pyogenic  bacteria  such  as  staphy- 
lococcus pyogenes  aureus.  Frequently  we  see  boils  scattered  through  the 
scalp  in  large  crops.  At  other  times  they  occur  singly.  A  boil  begins 
as  a  small,  red  spot  in  the  true  skin,  very  tender,  and  growing  larger  and 
larger.  On  palpation  the  center  is  soft  and  there  is  a  tendency  to  sup- 
puration. After  suppuration  has  taken  place,  and  the  boil  emptied,  the 
swelling  subsides.  A  furuncle  has  but  one  point  of  suppuration,  whereas 
the  carbuncle  has  many.  A  furuncle  is  usually  a  small  swelling.  A  car- 
buncle very  large,  frequently  several  inches  in  diameter. 

Treatment. — Aseptic  surgical  details  are  demanded  in  each  and  every 
instance.  The  scalp  should  be  shaved.  The  area  of  the  skin  involving  the 
furuncle  should  be  washed  with  carbolated  soap  and  water,  and  subse- 
quently with  water.  A  free  incision  should  be  made,  the  pus  liberated,  and 
the  part  dressed  with  sterile  gauze.     When  furuncles  recur,  then  specific 


836  DISEASES  OF  THE  SKIN. 

results  can  be  obtained  by  an  injection  of  an  autogenous  vaccine  made  from 
the  patient's  pus.  The  staphylococcus  pyogenes  vaccine  can  be  injected  in 
doses  of  500  million  daily.  No  more  than  five  or  six  injections  will  be 
needed  to  effect  a  cure.  I  have  also  had  good  results  with  stock  vaccine^  in 
injections  of  200  million,  with  an  initial  dose  of  100  million. 

Iron,  codliver-oil,  and  other  restoratives  are  indicatedj  The  value  of 
nutritious  food  must  not  be  overlooked. 

Chronic  Pemphigus.^ 

This  frequently  follows  the  acute  condition.  It  resembles  the  acute 
disease  in  producing  a  succession  of  crops  of  buUse. 

The  prognosis  depends  on  the  condition  of  the  child  at  the  time  when 
it  was  first  attacked.  If  the  infant  is  underfed,  and  its  vitality  lowered 
thereby,  then  active  restorative  treatment  should  be  instituted  or  the  ease 
will  be  lost. 

Treatment. — The  blebs  should  not  be  ruptured.  They  should  be  al- 
lowed to  dry.  The  surface  of  the  skin  in  the  immediate  neighborhood 
should  be  protected  by  a  bland,  non-irritating  ointment,  such  as  zinc  salve 
or  diachylon  salve. 

Sprinkling  powder  of  zinc  oxide,  borated  talcum,  or  cornstarch  should 
be  used.  If  the  bullae  rupture,  the  serum  should  be  absorbed  with  a  little 
cotton  and  the  neighboring  parts  protected  from  the  excoriating  effect  of 
the  contents  of  the  ruptured  bullae.  Careful  attention  must  be  given  to 
the  stomach  and  bowels.  If  necessary,  a  mild  laxative  should  be  given. 
The  diet  should  be  regulated  both  as  to  quantity  and  quality. 

JSTjevus. 

There  are  two  kinds  of  nsevus  usually  seen:  (a)  pigmentary;  (6)  vas- 
cular. Pigmentary  occur  as  small,  rounded  stains,  which  are  either  yel- 
lowish or  dark  brown.  The  cutis  is  raised,  thickened,  and  frequently  sur- 
rounded with  a  tuft  of  hair.  They  are  most  commonly  seen  on  the  face, 
neck,  and  hands. 

Vascular  natvi  may  be  level  with  the  skin  or  appear  as  tumors  which 
project  beyond  it.  The  former  is  due  to  an  excessive  development  of  the 
capillaries  of  the  skin.  Commonly  met  with,  it  is  of  a  purplish  hue, 
although  it  may  be  brick-red,  claret-red,  or  a  livid-hlue  color.  They  are 
most  commonly  seen  on  the  face  and  neck. 

Treatment. — Blistering  or  caustics  are  recommended  for  the  cure  of 
this  condition.     I  have  frequently  seen  marked  benefit  from  linear  scari- 


*  Purunculosis   vaccine    or    polyvalent    staphylococcus    vaccine.      Parke,    Davis 
&  Company. 

*  See  article  on  "Pemphigus  Neonatorum." 


TINEA  TONSURANS.  83? 

fication  by  the  Paquelin  cautery.    A  radical  operation  should  be  considered 
if  this  milder  form  of  treatment  is  unsuccessful. 

Tinea  Tonsurans   (Ringworm). 

This  disease  is  caused  by  the  trichophyton  tonsurans.  When  located 
©n  the  scalp  it  is  called  herpes  tonsurans;  when  on  other  parts  of  the 
body  it  is  known  as  herpes  circinatus. 

Microscopical  Appearance. — Squire  says:  "Under  the  microscope  the 
stump  of  the  hair  appears  ragged  on  either  of  its  ends.  Instead  of  break- 
ing with  a  clean  fracture,  like  healthy  hair,  the  broken  ends  are  digitated. 
The  structure  of  the  hair  is  greatly  altered;  its  fibers  are  separated  longi- 
tudinally, and  the  intervals  filled  with  the  spores  of  the  trichophyton.  On 
the  surface  of  the  hair  are  clusters  of  the  same  spores.  The  magnified 
piece  of  hair  looks  something  like  a  bundle  of  faggots,  with  a  number  of 
berries  sticking  in  clusters  to  its  sides  and  ends,  and  stuffed  here  and  there 
into  its  interstices.  The  spores  of  the  trichophyton  are  rounded,  have  a 
well-defined  outline,  and  measure  about  Vsooo  i^ch  across.  In  the  earlier 
stages  of  the  disease,  when  the  hair  has  not  yet  become  so  brittle  as  to 
make  it  impossible  to  extract  the  root,  it  can  be  ascertained  that  the  knob 
of  the  hair,  as  well  as  its  root-sheath,  is  invaded  by  the  spores  of  the  tri- 
chophyton." 

The  disease  commences  with  more  or  less  itching  and  redness  of  some 
parts  of  the  scalp ;  sometimes  there  is  swelling.  The  hair  growing  on  these 
patches  loses  its  polish,  and  becomes  dull.  It  is  also  brittle  and  easily  breaks 
off  near  the  root.  This  breaking  off  of  the  affected  hairs  gives  the  patch 
the  appearance  of  having  been  lately  shaved.  There  is  a  furfuraceous  des- 
quamation plainly  seen  on  the  scalp.  The  hair  follicles  become  erect  and 
the  patch  assumes  a  goose-skin  appearance.  The  margin  of  the  patch  is 
abruptly  defined.  There  are  usually  several  patches  seen  on  different  por- 
tions of  the  scalp.  If  we  attempt  to  pull  out  the  hair  stumps  by  means  of 
a  tweezer,  we  will  note  that  only  a  portion  of  it  comes  away,  leaving  the  hair 
root  in  the  skin. 

Treatment. — X-ray  treatment  was  introduced  by  Sabouraud  and  Noire 
as  a  remedy  that  is  promptly  curative  in  ringworm  of  the  scalp.  Their 
method  is  based  upon  one  measured  application  of  this  agent,  sufficient  to 
produce  depilation,  this  latter  ensuing  two  or  three  weeks  after  exposure, 
and  without  producing,  at  the  most,  more  than  the  mildest  x-ray  erythema. 
Care  must  be  exercised  so  that  the  slightest  reaction  is  not  exceeded ;  other- 
wise there  is  risk  of  permanent  baldness.  It  is  not  a  method  to  be  used 
by  those  inexperienced  in  the  use  of  the  x-ray. 

The  essence  of  the  method  of  Sabouraud  and  Noire  (who  use  static 
machines  for  generating  the  current)  consists  in  giving  one  exposure  suj0&- 
ciently  long  to  produce  depilation,  yet  not  long  enough  to  produce  ill 


838     .  DISEASES  OF  THE  SKIN. 

effects.  This  is  done  by  employing  some  means  of  measuring  the  quantity 
of  rays,  and  by  keeping  the  vacuum  of  the  tube  at  a  point  equal  to  about 
3-inch  spark  gap.  Full  directions  of  this  treatment  can  be  found  in  Stel- 
wagon's  "Diseases  of  the  Skin,"  1910. 

The  following  method  is  also  of  value : — 

Remove  the  superficial  scales  with  the  tincture  of  green  soap,  or  by 
the  use,  for  a  day  or  two,  of  the  pure  green  soap  spread  upon  a  piece  of 
lint.  Corrosive  sublimate  in  1  per  cent,  solution  may  be  applied  once  a 
day,  or  the  tincture  of  iodine,  or  carbolic  acid  in  glycerine,  1  to  16,  or  the 
white  precipitate  ointment  may  be  employed.  I  prefer  the  chrysarobin 
collodion  painted  over  the  patch  every  day  or  every  other  day.  Kaposi's 
naphthol  ointment  is  recommended  by  Lassar.  Tar  or  sulphur  ointments 
or  Lassar's  paste  may  be  employed  in  obstinate  cases. 

Morris's  thymol-chloroform  oil  is  also  beneficial. 

morris's  thymol-chloroform  oil. 

B  Thymol    1  part 

Chloroformi    4  parts 

01.  olivse  12  parts 

Or:— 

SUBLIMATE  SPIRIT. 

IJ  Hydrarg.  chlor.  corr 1  part 

Spts.  vini  rect 500  parts 

Or:— 

TANNIN-SULPHUB  PASTE. 

Ij(  Acidi  tannici   5      parts 

Lac.  sulph 10      parts 

Petrolati 50      parts 

Zinci  oxidi   17.5  parts 

Amyli    17.5  parts 

Or:— 

CHRYSAROBIN   COLLODION. 

IJ  Chrysarobini    ,  .      1  part 

Collodii  flexile 10  parts 

Vereuca  (Warts). 

These  small  tumors  of  the  skin  are  frequently  met  with  in  children. 
They  may  resemble  a  bunch  of  carrots  (verruca  digitata)  or  they  may 
resemble  a  cauliflower.  In  size  they  vary  from  one-sixteenth  to  one- 
eighth  of  an  inch  in  height.  They  frequently  are  seen  on  the  face,  neck,  and 
hands.    They  produce  no  discomfort  and  are  not  serious. 

Treatment. — Freeze  the  parts  with  ethyl  chloride  or  ether.  Pick  the 
wart  with  a  sharp  curette.  Another  painless  method  consists  in  cauterizing 
first  with  pure  carbolic  acid,  on  top  of  which  fuming  nitric  acid  is  applied. 


GANGRENE.  839 

In  using  the  latter  caustic  method,  the  surrounding  parts  should  be  pro- 
tected with  vaseline. 

Burns  (Combustio). 

We  frequently  see  burns  of  various  degrees  in  children. 

They  are  usually  caused  by  hot  water,  steam,  acids,  or  alkalies. 

An  intensely  inflamed  area  surrounding  a  blistered  surface  is  usually 
found.  Pain  and  sometimes  shock  are  noted.  In  some  cases  fever  and  a 
rapid  increase  in  the  pulse  are  noted.  Violent  reaction  such  as  convulsions 
frequently  occur  in  weak  and  rachitic  children  if  a  severe  burn  has  taken 
place. 

This  depends  upon  the  amount  of  surface  involved  and  on  the  condi- 
tion of  the  child  at  the  time  of  the  accident.  Some  children  survive  exten- 
sive burns  with  good  care.  As  a  rule  a  cautious  prognosis  should  be  given, 
owing  to  the  risk  of  infection  and  danger  of  shock. 

Treatment. — Strict  asepsis  should  govern  the  opening  of  all  blisters. 
Cornstarch,  wheat  flour,  europhen,  or  dermatol  may  be  used  locally.  In 
addition  thereto,  linseed-oil  and  lime  water,  or  calamine  and  zinc  lotion 
(see  chapter  on  "Eczema"),  is  very  valuable. 

Air  should  be  excluded  by  applying  an  ointment  consisting  of  10  per 
cent,  ichthyol,  1  per  cent,  menthol,  or  %  per  cent,  phenol  with  vaseline. 
In  some  cases  Fordyce  advises  the  use  of  1  per  cent,  picric  acid  ointment 
over  which  narrow  strips  of  oiled  silk  are  placed  to  prevent  the  dressings 
from  adhering.    Cover  with  sterile  gauze  and  bandage. 

Gangrene  (Superficial  GrANGRE"NE). 

This  condition  affecting  the  skin  or  extending  to  the  deeper  structures 
is  characterized  by  a  bluish-black  discoloration  resembling  a  deep  form  of 
cyanosis. 

Causes. — It  is  a  destructive  condition  following  the  acute  infectious 
diseases,  especially  scarlet  fever  or  measles.  Traumatism  or  pressure  inter- 
fering with  the  circulation  of  the  blood  or  robbing  the  extremity  of  its 
nutrition  may  result  in  a  destructive  gangrene.  The  following  case  of 
traumatic  gangrene  occurred  in  my  practice;  it  was  a  traumatic  gangrene 
due  to  interference  with  the  circulation: — 

Baby  A.,  ten  months  old,  breast-  and  bottle-  fed,  was  referred  to  me  by  Dr.  A. 
Meyer.  I  found  a  temperature  of  105°  F.,  pulse  180,  respiration  60.  There  was  com- 
plete consolidation  of  one  lobe  of  the  left  side.  Bronchial  breathing  was  plainly 
heard  and  there  was  dullness  on  percussion. 

The  diagnosis  of  lobar  pneumonia  was  made.  With  the  aid  of  cold  packs  and 
small  doses  of  strychnine,  the  child's  condition  improved.  As  I  left  the  city,  the  case 
was  treated  by  Dr.  Khodoflf,  who  gave  me  the  following  memoranda: — 

"The  nurse  administered  a  high  rectal  enema  by  suspending  the  child  with  a 
towel  around  the  thighs.    The  circulation  was  thereby  interfered  with.    I  believe  the 


840 


DISEASES  OF  THE  SKIN. 


thrombosis,  which  appeared  at  about  the  saphenous  opening,  was  of  traumatic  origin 
due  to  this  interference  of  the  circulation.  The  course 'of  the  gangrene  was  as 
follows:  A  bluish-purple  spot  about  the  size  of  a  ten-cent  piece  appeared  at  the 
saphenous  opening.  The  child  previous  to  this  showed  indications  of  pain.  It  was 
fretful,  tossing  about,  and  very  restless.  The  gangrenous  area  increased  on  the 
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Fig.  282. — Case  of  Gangrene  Following  Lobar  Pneumonia.  Gangi-ene 
appeared  on  the  tenth  day  of  disease,  due  to  a  careless  method  of  suspending 
the  child  by  a  towel  around  the  thighs,  which  resulted  in  thrombosis,  ending 
fatally.     (Original.) 

appeared,  a  rapid  spreading  took  place  upward  along  Poupart's  ligament  and  con- 
tinued above  and  involved  the  umbilicus." 

When  I  again  saw  this  case  the  gangrene  involved  the  whole  abdomen.  The 
temperature  was  102°  F.,  the  pulse  very  feeble,  and  the  child  in  a  state  of  collapse. 
It  was  necessary  to  stimulate  and  feed  per  rectum.    The  child  died  in  eommlsions. 

Prognosis. — The  prognosis  is  always  bad,  although  surgery  may  be 
the  means  of  amputating  a  gangrenous  extremity  and  saving  the  rest  of 
the  body. 

Treatment. — ^There  is  no  medicinal  treatment  worth  trying.  Surgical 
relief  is  our  only  hope. 


SCABIES.  841 

Symmetrical  Gangrene  (Raynaud's  Disease). 

This  is  an  obscure  condition  in  which  the  gangrene  is  symmetrical. 

Etiology. — It  is  caused,  no  doubt,  by  the  invasion  of  pathogenic  bac- 
teria. Infectious  diseases  which  devitalize  the  body  are  believed  to  pre- 
dispose to  this  condition.  Injury  and  haemorrhages,  such  as  epistaxis,  have 
been  forerunners  of  this  condition. 

Symptoms. — When  acute  there  is  fever  and  enlargement  of  the  spleen, 
hgematuria,  or  hgemoglobinuria.  The  affected  part  feels  cold  and  appears 
bluish;  sometimes  there  are  vesicles  containing  a  sero-purulent  fluid.  This 
condition  lasts  from  two  to  three  weeks,  although  it  may  extend  over  many 
months.  The  disease  ends  in  mummification  and  gradual  decay  of  the 
affected  parts.  The  toes,  fingers,  ears,  or  tip  of  the  nose  may  be  the  seat 
of  this  affection. 

Prognosis. — A  cautious  prognosis  should  always  be  given.  While 
records  of  cures  exist,  the  diagnosis  may  always  be  questioned. 

Treatment. — General  restorative  treatment,  concentrated  foods,  and 
hygiene  should  form  the  basis  of  treatment.  The  skill  of  the  surgeon  may 
eradicate  the  gangrenous  parts. 

Scabies. 

This  is  a  contagious  disease  caused  by  the  female  acarus  burrowing  into 
the  skin.  The  characteristic  features  of  this  disease  are  that  it  is  found 
between  the  fingers,  in  the  axillae,  on  the  flexor  surfaces  of  the  wrists,  and 
also  around  the  genitals.  The  eruption  is  either  a  papule  or  a  vesicle,  some- 
times a  pustle.  There  is  an  intense  itching,  and  secondary  infection 
results  from  scratching.  Several  children  in  the  same  family  will  usually 
be  found  so  affected. 

The  prognosis  is  always  good. 

Treatment. — A  hot  bath,  to  thoroughly  soak  the  body  and  soften  the 
epithelial  scales,  should  be  ordered.  An  inunction  of  Vg  unguentum 
hydrarg.,  2/3  vaseline  should  follow  the  bath.  Sulphur  soap  may  be  used  in 
addition  to  sulphur  ointment  if  no  benefit  results  from  the  foregoing 
treatment. 

Epicarin  is  unirritating  and  is  of  value  in  parasitic  affections  of  the 
skin.    Precip.  sulphur  sprinkled  between  the  sheets  at  night  affords  relief. 

An  excellent  method  advised  by  Fordyce  is,  first,  a  cleansing  bath,  fol- 
lowed by  applications  of  the  following: — 

IJ  Balsam  Peru 1  drachm 

Sulphur ^2  drachm 

Betanaphthol   10  grains 

Petrolatum 1  ounce 

-     M.    Sig. :    Apply  on  affected  areas.     Repeat  treatment  three  successive  nights. 

Strict  supervision  must  be  kept  up  for  at  least  ten  days. 


CHAPTER  IV. 

MALIGNANT  AND  NON-MALIGNANT  GROWTHS.^ 

Abnormal  growths  are  frequently  seen  in  children.  Some  of  these 
are  malignant,  while  some  are  benign.  We  must  not  suppose  that  children 
do  not  have  malignant  disease.  I  have  seen  malignant  sarcoma  involving 
the  whole  of  the  left  lung  which  crowded  the  heart  into  the  right  axillary 
space. 

Spindle-oell  Sarjdoma  of  the  Thoeax.2 

Gustav  L.,  a  male  child  of  about  8  years,  was  first  seen  by  me  in  July,  1900. 
His  mother  gave  the  following  history: — 

He  was  breast-fed  about  ten  weeks  and  owing  to  a  diminution  in  the  quantity 
and  quality  of  her  milk,  she  was  forced  to  wean  the  child.  He  then  received  sterilized 
milk.  This  food  was  given  until  the  child  was  weaned  from  the  bottle  at  about  the 
end  of  his  second  year. 

When  about  six  months  of  age,  a  large,  glandular  swelling  commenced  behind 
the  right  ear,  which  necessitated  an  incision.  The  attending  physician  said  it  was 
an  abscess.  At  this  same  time,  he  had  a  severe  attack  of  gastric  fever.  This  required 
careful  dietetic  treatment.    Cow's  milk  was  continued  in  a  more  modified  form. 

At  age  of  1  year  the  child  was  attacked  with  measles,  accompanied  by  a 
catarrhal  bronchitis.  Some  cough  remained  and  when  the  child  was  2  years  old  he 
had  a  severe  attack  of  pertussis.  When  the  child  recovered,  he  remained  well  until 
he  was  3  V2  years  old,  then  he  Was  infected  with  scarlet  fever  lasting  two  months. 
Thus  the  child  passed  his  infancy  with  some  gastric  derangement,  followed  by  measles, 
pertussis,  and  scarlet  fever.     He  did  not  have  croup  or  diphtheria. 

"Family  History. — This  is  good.  The  parents  of  this  patient  are  both  living,  and 
apparently  strong  and  healthy;  they  have  two  other  boys,  well  and  strong.  There  is 
no.  history  of  syphilis,  rheumatism,  gout,  tuberculosis,  epilepsy,  nor  anything  of  a 
malignant  nature  in  the  family,  excepting  this  fact  which  is  extremely  noteworthy, 
that  the  grandfather  had  a  sarcomatous  tumor,  which  ended  fatally. 

"Examination. — The  patient  was  brought  to  me  for  the  relief  of  a  number  of 
tumors  on  the  front  of  the  thorax,  which  felt  quite  hard  on  palpation.  At  times  a 
distinct  sense  of  fluctuation  could  be  made  out,  and  when  examined  By  an  exploratory 
puncture,  a  few  drops  of  thin,  yellowish  serum  was  obtained.  These  tumors  have 
been  very  troublesome  for  the  past  few  years.  They  have  caused  severe  dyspnoea. 
The  physician  who  treated  this  boy  in  Hamburg  believed  that  the  growths  contained 


"■For  complete  list  surgical  works  should  be  consulted. 

"  Read  before  the  Section  on  Pediatrics,  the  New  York  Academy  of  Medicine, 
April  10,  1902. 

(842) 


SAKCOMA    OF    'J  HE    THORAX. 


843 


pu9.  This  statement  was  made  to  the  family.  The  physician  made  an  exploratory 
puncture  and  was  rewarded  by  a  few  drops  of  thin,  seroas  liquid,  as  in  a  puncture  I 
made  and  obtainetl  no  pus. 

''The  size  of  the  growth  as  seen  extemally  is  about  15  centimeters  in  length 
and  about  G  to  7  centimeters  in  circumference.  (See  Fig.  283.)  There  is  marked 
dullness  on  percussion  e.xtending  over  most  of  the  left  side.  The  tumor  is  surrounded 
bj'  a  network  of  veins,  intensely  engorged  with  blood.  There  is  mediastinal  pressure. 
As  far  as  can  be  seen  and  palpated,  the  growth  occupies  that  region  of  the  thorax 
usually  occupied  hy  the  heart.     The  giowth  varies  in  size  from  week  to  week. 

''The  heart  has  been  pushed  to  the  right  side  and  occupies  the  right  axilla.  The 
apex  beat  is  heard  about  two  finger  breadths  below  and  to  tlie  right  of  the  right 
nipple.     (See  figure  284.) 

"The  pulse  is  144,. small,  feeble,  quite 
in*egular  and  eii.sily  com^jressible.  The 
respiration  is  irregular,  of  the  Cheyne- 
Stokes  type,  and  frequently  sighing.  It 
is  usually  about  50-52  in  a  minute;  the 
temperature  is  always  above  normal  and 
varies  from  100°  F.  in  the  rectmn,  morn- 
ing, to  101  Vo"  in  the  evening.  Tliere  is 
always  a  febrile  tendency. 

"There  is  constant  dyspnoea  and  also 
extreme  cyanosis  of  the  lips,  fingers  and 
toes.  The  child  is  very  pale  and  in  a 
very  anaemic  condition.  There  is  extreme 
pallor  of  the  conjunctival  membrane,  the 
gums,  and  the  mucous  membrane  of  the 
lips." 

Owing  to  the  extreme  amount  of 
weakness  caused  by  anorexia,  the  child 
was  compelled  to  remain  in  bed  most  of 
the  time  for  the  last  year.  Dyspnoea  was 
so  great  that  the  child  slept  in  a  sitting 
posture.  The  child  was  very  nei-vous  and 
trembled  when  he  was  touched.  He  was 
very  bright  mentally.  There  was  con- 
stant and  rapid  emaciation.  Concen- 
trated food  was  given,  which  the  patient 
took  quite  well.  There  was  extreme 
hypersesthesia  of  the  skin.  The  digestion 
was  quite  good,  and  altjiough  the  bowels 
moved  sluggishly,  they  did  not  require 
much  medicinal  treatment.  Fiuit  and  fruit  juices  acted  as  laxatives.  There  was  a 
cur\'ature  of  the  spine  from  left  to  right,  most  marked  in  the  dorsal  vertebra.  The 
urine  was  examined  several  times.  It  showed  no  evidence  of  pus  or  blood,  no 
albumin  and  no  sugar.  There  was  a  slight  indican  reaction.  No  acetone,  no  casts, 
no  morphotic  elements,  microscopically. 

The  case  w^as  hopeless  from  a  medical  standpoint,  as  the  groArth  was  constantly 
increasing.  The  child  suffered  constantly  from  insortinia  and  great  dyspnoea,  requir- 
ing constant  soporifics  and  narcotics.  In  spite  of  the  grave  prognosis,  the  family 
hoped  that  s\irgical  measures  might  afford  some  relief. 


Fig.  283.— Spindle-cell  Sarcoma. 
The  prominence  of  the  tumor  shows 
by  contrast  the  emaciation  of  the 
body.     (Original.) 


844 


ABNORMAL    GROWTHS. 


As  the  tumor  frequently  appears  to  show  a  distinct  pointing,  this  latter 
condition  suggesting  fluid,  an  anaesthetic  was  given  with  the  assistance  of  Dr.  J.  W. 
Wurthman.  The  anaesthetic  was  badly  borne  and  I  succeeded  with  diflficulty  in 
making  two  exploratory  punctures. 

An  x-ray  examination,  to  verify  the  clinical  data,  was  made  by  Dr.  C.  Beck,  to 
whom  the  case  was  referred.     The  heart  could  be  plainly  seen  pulsating  on  the  right 


Fig.    284.-— Anterior  View  of  the  Tumor.     Showing  al«o  the  position  of  the 
displaced  heart  and  the  enlarged  veins.     (Original.) 


side.  No  definite  satisfactory  data  could  be  learned  concerning  the  tumor,  on 
account  of  the  restlessness  of  the  patient,  and  the  child  was  removed  to  St.  Mark's 
Hospital  and  operated.    The  child  died  soon  after  the  operation. 

A  specimen  of  the  tumor,  removed  during  the  operation,  was  sent  by  me  to  Dr. 
Mandlebaum,  for  a  pathologic  examination.  He  reported  the  tumor  to  be  a  spindle- 
cell  sarcoma  in  a  rather  active  state  of  growth,  on  account  of  the  large  number  of 
mitoses  present.     The  fluid  contained  simply  red  blood  cells  and  no  pus. 


HYPERNEPHROMA.  845 

Sarcomatous  growths  in  children  are  quite  rare,  though  met  with  from 
time  to  time.  Thus  Mauderli,  in  the  Children's  Hospital  of  Basle,  Swit- 
zerland, reports  for  the  last  twenty  years  that  he  treated  a  total  of  10 
patients :  7  boys  and  3  girls,  of  whom  4  were  under  3  years  of  age,  3  were 
between  3  and  6  years,  1  was  between  G  and  9  years,  and  2  were  between 
9  and  12  years. 

As  but  one  case  of  malignant  sarcoma  was  met  with  in  this  hospital 
in  the  course  of  the  last  twenty  years  in  children  as  old  as  the  case  here 
reported  by  me,  I  feel  justified  in  adding  mine  to  those  already  recorded. 

The  interesting  points  about  my  case  were:  (1)  The  displaced  heart, 
the  heart  being  immediately  behind  the  right  nipple.  The  pulsations  and 
apex-beat  could  be  distinctly  felt  and  seen  about  two  finger-breadths  below 
the  right  nipple.  (2)  The  intense  dyspnoea  caused  by  pressure  of  the 
tumor.  (3)  Constant  cyanosis  and  oedema  of  the  limbs,  due  to  interference 
with  the  return  circulation  to  the  right  side  of  the  heart. 

Caecinoma. 

Carcinoma  is  occasionally  found  in  children.  Malignant  growths  of 
this  kind  have  been  diagnosed  and  verified  by  microscopical  examinations. 

Hypeenephroma. 

Literature  records  many  cases  of  hypernephroma  in  children.  The  fol- 
lowing.case^  was  seen  by  me  in  a  boy  16  years  of  age:  The  case  was  brought 
to  me  with  a  history  of  hsematuria.  The  bloody  urine  was  noticed  several 
weeks,  and  was  probably  due  to  injury  caused  by  carrying  some  boxes,  while 
working  on  a  farm.  No  apparent  discomfort  nor  pain  was  evidenced  for 
many  weeks,  when  a  small  swelling  developed  over  the  region  of  the  spleen. 
Subjective  symptoms,  such  as  pain,  were  described  and  there  was  a  slight 
rise  in  temperature.  The  swelling  increased  from  day  to  day.  A  radiogram 
was  taken  by  Dr.  Caldwell.  The  diagnosis  of  tumor  was  made  and  the  pa- 
tient was  operated  by  Dr.  John  Erdman.  The  tumor  was  removed  and 
proved  to  be  a  hypernephroma.  Eadiograms  of  the  long  and  flat  bones 
revealed  a  series  of  tumors  in  the  spine,  scapula,  and  femora. 

The  patient  died  of  emaciation  and  exhaustion  within  a  year. 

Lipoma. 

Fatty  growths  are  occasionally  seen  in  children.  They  occur  on  the 
scalp,  on  the  back,  and  I  have  seen  them  on  the  buttocks.  They  require 
the  same  treatment  as  fatty  growths  in  adults.  (See  article  in  the  section 
on  "New-born  Baby"  on  "Congenital  Sacral  Tumor.") 

^  For  complete  clinical  history  of  this  case  see  Archives  of  Pediatrics,  Novem- 
ber, 1914." 


846  ABNORMAL  GROWTHS. 

Enchondromata. 

These  hard  growths  are  usually  found  on  the  fingers  and  toes.  They 
are  found  in  the  neighborhood  of  the  joints,  with  which  they  are  closely 
allied.  A  case  of  this  kind  which  had  several  tumors  removed  occurred  in 
my  practice : — 

Mary  B.,  10  years  old. 

Family  History. — Father  healthy.  Mother  died  of  carcinoma  of  the  uterus. 
Has  one  sister,  who  is  healthy  and  married. 

Patient's  History. — Was  breast-fed  during  infancy.  Suffered  with  no  gastric 
or  enteric  disorders.  Had  measles  when  several  years  old.  Is  not  subject  to  any 
chronic   disease.      Her    extremities   are    normal    excepting   the    affected   hand.      The 


Fig.    285. — Enchondromata  Involving  the  Thumb  and 
Index  Finger.     (Original.) 

mother  stated  the  tumors  had  been  present  soon  after  birth.  They  were  not  painful, 
nor  did  they  cause  discomfort,  so  nothing  was  done  until  the  child  reached  this  age. 
The  case  was  referred  by  me  to  the  surgical  service  of  Dr.  S.  M.  Landsman,  who  re- 
moved the  giowths.     The  case  made  a  perfect  recovery. 

■  ,  ■     Spina  Bifida. 

Abnormal  growths  are  frequently  found  in  the  lumbar  region  asso- 
ciated with  the  spinal  cord.  They  are  frequently  seen  in  cases  of  hydro- 
cephalus. A  case  of  spina  bifida  is  reported  in  the  chapter  on  "Malforma- 
tions of  the  Spine." 

Angeioma. 

Angeioma. — Large  vascular  growths  are  occasionally  seen  in  children. 
A  case  of  this  kind  was  seen  by  me,,  which  I  describe  in  the  chapter  on  the 
"New-born  Baby,"  page  57. 


GRANULOMATA.  347 


Papillomata. 


This  growth  is  occasionally  seen  in  the  larynx  of  infants  and  children. 
It  may  be  congenital. 

Symptoms. — Marked  dyspnoea  is  usually  a  prominent  symptom.  This 
dyspnoea  increases  with  the  enlargement  of  the  growth.  There  is  also  a 
husky  voice,  which  increases  in  severity.  The  symptoms  are  very  marked 
at  night,  but  are  much  less,  and  frequently  disappear  entirely,  during  the 
day.  Cough  may  also  be  present,  but  no  expectoration.  There  is  no  fever. 
The  diagnosis  is  usually  made  by  a  laryngoscopic  examination.  When  the 
same  symptoms  appear  for  weeks  and  months,  a  laryngeal  growth  should 
be  suspected. 

Treatment.— Eemoval  of  the  growth  with  an  angesthetic  is  absolutely 
necessary.  The  danger  in  removing  the  growth  should  always  be  borne  in 
mind;  hence  the  surgeon  should  be  prepared  to  perform  a  tracheotomy  if 
necessary.  Intubation  of  the  larynx  will  relieve  the  difficult  breathing;  at 
the  same  time  there  is  danger  of  pushing  some  of  this  growth  with  the  tube, 
thus  obstructing  the  caliber  of  the  same.    Eelapses  are  common. 

Granulomata.^ 

These  growths  are  frequently  seen  at  the  site  of  the  wound  following  a 
tracheotomy.    They  resemble  a  mass  of  exuberant  granulations. 

Prof.  A.  Eosenberg,  of  Berlin,  collected  231  cases  of  laryngeal  tumors 
in  children.  Some  of  them  were  subjected  to  tracheotomy;  others  received 
endo-laryngeal  treatment  preceded  by  tracheotomy.  In  another  series  of 
cases  persistent  endo-laryngeal  treatment  was  resorted  to  without  perform- 
ing tracheotomy.    This  latter  method  yielded  the  better  results. 


^  In  Part  II,  page  35,  will  be  found  article  on  "Granuloma.' 


PART  XI. 

DISEASES  OF  THE  SPINE  AND  JOINTS. 


Pott's  Disease.^ 

This  disease  derives  its  name  from  Percival  Pott,  who  described  it 
in  1779.  "It  is  a  chronic  destructive  process  which  begins  in  the  bodies 
of  the  vertebrae.  The  bodies  of  the  vertebrae  support  the  weight  of  the  body. 
As  the  disease  progresses  the  weakened  parts  give  way,  and  the  upper  seg- 


Fig.  286.— Pott's  Dis- 
ease ( Langerhans ) .  Ky- 
phosis of  dorsal  vertebrae, 
the  result  of  caseous  .tu- 
berculous periostitis  and 
osteomyelitis.  Destruc- 
tion of  three  thoracic  ver- 
tebrse.  Two-thirds  na;t- 
ural  size. 


ment  inclines  forward.  An  angular  posterior  projection,  TcypliosiSj  is 
formed  which  is  the  characteristic  xieformity  of  the  disease." 

Etiology. — "Pott's  disease  may  appear  at  any  period  of  life,  from 
earliest  infancy  to  old  age,  but  like  all  forms  of  tuberculosis  of  the  bones, 
it  is  most  common  in  the  first  ten  years  of  life,  and  50  per  cent,  of  the 
cases  begin  between  the  ages  of  3  and  5  years,  inclusive. 

"The  lower  segment  of  the  spine,  including  the  dorso-lumbar  region, 
is  most  often  involved.     Cervical  disease  is  relatively  infrequent  (cervical, 


^  The  table  of  differential  points  between  Pott's  Disease  and  Rickets  will  be 
found  on  page  321. 
(848) 


POTT'S   DISEASE.  849 

7  V2  per  cent.;  dorsal,  G8  per  cent.;  lumbar,  24  per  cent.).  The  death 
rate  is  at  least  25  per  cent.  The  course  of  the  disease  is  most  protracted  in 
the  middle  region;  it  is  shortest  in  the  cervical  region,  its  duration  vary- 
ing in  favorable  cases  from  two  to  five  years. 

''When  the  local  resistance  overcomes  the  tendency  to  degeneration, 
the  process  of  repair  begins.  The  tuberculous  products  are  absorbed  or 
enclosed,  and  ankylosis  between  the  two  segments  of  the  spine  is  estab- 
lished by  means  of  a  union,  in  part  fibrous,  cartilaginous,  and  bony.  Firm 
union  is  long  delayed,  and  the  deformity  may  increase  long  after  the 
disease  has  become  inactive"    (Whitman). 

Pathology  and  Bacteriology. — "The  first  indications  of  disease  are 
most  often  found  beneath  the  fibro-periosteal  layer  of  the  anterior  longi- 
tudinal ligament.  From  this  point  the  granulation  tissue  advances  along 
the  course  of  the  blood-vessels  into  the  adjacent  bone,  extending  from 
one  to  another  until  several  bodies  are  more  or  less  involved.  The  disease 
is  accompanied,  in  many  instances,  by  an  abscess,  which  may  be  of  suffi- 
cient size  to  cause  special  symptoms;  or  the  tuberculous  process  may  find 
its  way  to  the  posterior  part  of  the  vertebral  bodies  and  thus  involve  the 
spinal  cord,  causing  paralysis.  Abscess  is  most  common  as  a  complication 
of  disease  of  the  lower  part  of  the  spine,  where  it  may  be  detected  in  at 
least  50  per  cent,  of  the  cases.  Paralysis  most  often  complicates  disease 
of  the  upper  dorsal  region,  appearing  in  about  10  per  cent,  of  the  cases 
in  which  this  part  of  the  spine  is  involved.  The  primary  infection  is  no 
doubt  due  to  the  entrance  of  the  tubercle  bacillus.^^ 

Anatomical  Landmarks. — "The  atlas  is  on  a  line  with  the  hard  palate. 
The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth.  The  transverse 
process  of  the  atlas  is  just  below  and  in  front  of  the  tip  of  the  mastoid 
process.     The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

"The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  vertebra. 

"The  upper  margin  of  the  sternum  is  opposite  the  disc  between  the 
second  and  third  dorsal  vertebrae.  ' 

"The  junction  of  the  first  and  second  sections  of  the  sternum  is  op- 
posite the  fourth  dorsal  vertebra. 

"The  tip  of  the  ensiform  cartilage  is  opposite  the  lower  part  of  the 
body  of  the  tenth  dorsal  vertebra. 

"The  anterior  extremity  of  the  first  rib  is  on  a  line  with  the  fourth 
rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  with  the  ninth,  the 
seventh  with  the  eleventh. 

"The  scapula  covers  the  second  and  the  seventh  ribs,  its  lower  angle 
being  opposite  the  center  of  the  eighth  dorsal  vertebra. 

"The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and  the 
interval  bet^vcen  the  second  and  third  dorsal  spines  are  in  the  same  plane. 

*'The  most  constant  landmark  from  which  to  count  is  the  spinous 


850  DISEASES    OF    THE    SPINE    AND    JOINTS. 

process  of  the  fourth  lumbar  vertebra^  which  is  on  a  line  with  the  highest 
point  of  the  crest  of  the  ilium.     The  umbilicus  is  near  the  same  plane. 

"The  tip  of  the  coccyx  is  opposite  the  lower  border  of  the  symphysis 
pubis." 

Symptoms. — If  the  upper  part  of  the  spine  is  affected,  a  stiffness  of 
the  neck  usually  exists.  If  the  lower  part  of  the  spine  is  affected,  limping 
will  be  noticed,  hence  awkwardness  in  walking  in  very  anasmic  children 
should  always  be  looked  upon  as  suspicious. 

"The  limitation  of  motion  due  to  muscular  spasm,  to  pain,  and  to  the 
local  disease  is  an  important  factor  in  diagnosis.  This,  together  with  the 
deformity,  may  be  demonstrated  by  bending  the  patient's  body  directly 
forward  to  the  fullest  extent.  An  object  is  next  placed  on  the  floor,  and 
the  patient  is  directed  to  jjick  it  up.  If  this  is  done  awkwardly  by  squat- 
ting or  kneeling,  it  demonstrates  weakness  and  stiffness.  The  patient 
should  next  be  placed  prone  upon  a  table,  and  the  surgeon  should  test  the 
flexibility  of  the  spine  by  lifting  the  legs  and  swaying  the  body  from  side 
to  side.  The  range  of  extension  at  the  hips  may  be  tested  at  this  time  by 
holding  the  pelvis  against  the  table  with  one  hand,  while  the  thigh  is  over- 
extended with  the  other.  This  is  the  test  for  the  slight  degree  of  psoas 
contraction  that  is  often  present  on  one  or  both  sides  in  disease  of  the 
lower  region. 

"The  flexibility  of  the  upper  part  of  the  spine  may  be  tested  by  vol- 
untary and  passive  movements  of  the  head  in  various  directions,  and  the 
range  of  motion  of  the  occipito-atlo-axoid  joints  by  holding  the  neck  while 
the  patient  nods  and  turns  the  head  from  side  to  side. 

"The  character  and  the  extent  of  the  deformity,  if  it  be  present,  should 
next  be  investigated.  K"ote  the  contour  of  the  spine.  Any  change  from 
the  normal  are,  in  childhood,  suspicious  circumstances.  N'ote  the  elastic- 
ity of  the  spine.  If  when  the  child  is  bent  forward  the  spine  forms  a  long, 
regular,  even  curve,  disease  is  unlikely.  If  there  be  a  break  in  the  outline, 
and  if  one  part  remains  rigid  and  another  bends,  disease  may  be  suspected." 

Pott's  disease  in  the  lower  region  of  the  spine  presents  the  following 
characteristics : — 

1.  Pain. — The  pain  is  referred  to  the  lower  part  of  the  abdomen,  to 
the  genitals,  to  the  loins,  or  to  the  thighs. 

2.  Gait. — JThe  waddling  gait  which  has  been  described  under  general 
symptomatology  is  characteristic  of  disease  in  this  region.  In  some  cases 
there  is  a  limp. 

3.  Attitude. — Usually  an  abnormal  erectness  and  sometimes  an  ex- 
aggerated lordosis;  in  some  instances  a  lateral  inclination  of  the  body. 
Unilateral  psoas  contraction  and  the  attendant  limp  are  often  present. 

4.  Stiffness.  —  Muscular  rigidity  of  the  lumlDar  region  interferes 
directly  with  almost  every  attitude  and  movement.     The  effect  of  this 


POTT'S    DISEASE.  g^i 

stiffness  and  of  the  accompanying  weakness  may  be  demonstrated  by  the 
popular  method  of  asking  the  child  to  pick  up  a  coin  from  the  floor.  In 
this  region  of  the  spine  the  symptoms  are  usually  well  marked  before  the 
stage  of  deformity,  flexion  of  the  legs,  the  effect  of  psoas  contraction,  and 
abscess  are  present  in  perhaps  a  third  of  the  cases. 

Pott's  disease  of  the  middle  region  is  characterized  by  the  following 
peculiarities : — 

1.  Pain  is  referred  to  the  lateral  region  of  the  thorax  or  to  the  front 
of  the  body.  It  is  a  common  symptom.  It  is  noted  after  sudden  move- 
ments or  after  compressing  the  chest,  as  when  the  child  is  suddenly  lifted 
from  the  floor. 

2.  Respiration. — If  the  disease  is  at  all  active,  a  grunting  respiration 
is  usually  present,  especially  after  exertion.  This  is  the  most  characteristic 
of  all  symptoms,  especially  so  in  young  subjects. 

3.  Attitude. — This  is  not  always  distinctive,  but  usually  there  is  a 
peculiar  shrugging  squareness  of  the  shoulders;  occasionally  a  lateral  in- 
clination of  the  body.  The  head  is  often  inclined  backward.  The  neck 
seems  short  on  account  of  the  elevation  of  shoulders. 

4.  Deformity. — The  deformity  is  usually  prominent  and  it  appears 
early  in  the  disease. 

5.  Complications. — The  most  common  complication  of  dorsal  disease 
is  paralysis,  abscess  being  less  frequent  than  in  the  lumbar  region.  Flat 
chest  and  chicken  breast  may  be  secondary  deformities. 

Pott's  disease  of  the  upper  region  presents  the  following  peculiari- 
ties : — 

1.  If  the  uppermost  cervical  vertebrae  are  diseased,  the  pain  is  referred 
to  the  head,  particularly  to  its  lateral  and  posterior  aspects.  In  disease  of 
the  middle  cervical  region  it  is  referred  to  the  neck,  or  to  the  shoulders 
or  chest. 

2.  The  weaTcness  and  stiffness  are  manifest  by  the  attitude.  The  head 
cannot  be  turned  freely.  If  the  disease  be  in  the  occipito-axoid  region, 
the  nodding  and  rotary  motions  are  restricted.  The  chin  is  often  depressed 
and  slightly  turned  to  one  side.  Lateral  distortion  resembling  torticollis 
usually  occurs  when  disease  is  nearer  the  middle  of  the  cervical  region. 

3.  The  bony  deformity  is  often  slight  or  absent,  but  thickening  of  the 
tissues  about  the  spine  and  local  sensitiveness  to  lateral  pressure  are  usu- 
ally present.  Eetro-pharyngeal  abscess  is  not  uncommon  when  the  atlo- 
axoid  region  is  involved. 

Complications. —  (a)  Abscess;  (b)  Paralysis:  About  25  per  cent,  of 
all  cases  have  abscess.  An  abscess  situated  in  the  atlo-axoid  region  often 
burrows  into  the  retro-pharyngeal  space.  It  may  involve  the  cranial  cavity 
when  this  occurs;  symptoms  of  meningitis  will  be  noticed.  When  an 
abscess  forms  from  disease  of  the  middle  cranial  region  it  usually  opens 


853  DISEASES    OF    THE    SPINE    AND    JOINTS. 

on  the  side  of  the  neck,  before  or  behind  the  sterno-cleido  mastoid  region; 
When  abscess  follows  disease  in  the  dorsal  region  it  burrows  through  the 
thorax.  It  can  be  detected  by  the  physical  signs  accompanying  pain  (see 
chapter  on  "Empyema"). 

When  it  burrows  downward  it  may  give  rise  to  an  iliac  or  lumbar  ab- 
scess. "In  disease  of  the  lumbar  region,  the  abscess,  if  superficial  to  the 
ilio-psoas  muscle,  may  point  in  the  neighborhood  of  the  anterior  superior 
spine,  or  pass  through  the  inguinal  ring.  The  true  psoas  abscess  first  dis- 
tends the  niac  region,  and  then  passing  into  the  thigh,  appears  in  Scarpa^s 
space.  In  large  abscesses  of  this  character  the  pus  may  find  an  exit  in  the 
loin  at  the  triangle  of  Petit,  or  in  the  gluteal  region  through  the.  sacro- 
sciatic  foramen. 

"In  rare  instances  the  abscess  may  find  an  opening  within  the  body, 
and  burst  into  the  lungs,  the  intestines,  or  elsewhere. 

"As  a  rule  abscess  causes  but  little  difficulty  in  diagnosis,  because  it  is 
a  late  symptom,  appearing  after  the  diagnosis  of  Pott's  disease  has  been 
established.  It  is  more  often  an  early  symptom  in  the  upper  and  lower 
regions  of  the  spine,  but  in  any  event  it  is  always  accompanied  by  symp- 
toms of  the  underlying  disease  of  the  spine." 

Paralysis. — The  symptoms  of  Pott's  paralysis  are  "an  awkward  stumb- 
ling gait,  weakness,  and  finally  an  inability  to  stand.  The  lower  limbs  are  . 
'stiff'  at  times.  The  reflexes  are  increased.  Control  of  the  bladder  may  be 
retained,  but  often  there  is  active  incontinence;  that  is,  the  bladder  emp- 
ties itself  from  time  to  time.  If  the  pressure  is  directly  upon  the  reflex 
centers  in  the  lumbar  enlargement,  there  may  be  passive  incontinence  or 
dribbling  of  urine.  If  the  pressure  is  below  the  reflex  centers,  the  bladder 
is  not  affected,  and  the  symptoms  of  numbness  and  weakness  resemble  those 
caused  by  neuritis." 

Differential  points  concerning  abscess : — 

1.  Abscess  of  the  cervical  region  must  not  be  confounded  with  the 
symptoms  of  enlarged  tonsils,  adenoids,  or  with  so-called  croup.  It  must 
also  be  distinguished  from  the  simple  acute  abscesses  of  this  region. 

3.  Abscess  of  the  thoracic  region  is  to  be  distinguished  from  those 
secondary  to  disease  of  the  lung  or  of  the  chest  wall. 

3.  Abscess  in  the  loin  or  inguinal  region  may  be  mistaken  for  the 
acute  or  chronic  abscess  due  to : — 

,    ,  p    .       ,    . . .  j"  These  are  usually  of  acute  onset  and  are  ac- 

^      companied  by  constitutional  disturbances. 
C  There  may  be  secondary  rigidity  of  the  spine, 

(h)  Perityphlitis.  J       but  no  deformity,  as  is  usual  in  Pott's  dis- 

[^      ease  at  the  stage  of  abscess  formation. 

(c)  Sacral  or  iliac  disease.      The  symptoms  of  Pott's  disease  are  lacking. 

(d)  Hernia. 


POTT'S    DISEASE. 


853 


The  paralysis  of  Pott's  disease  must  be  distinguished  from 

1.  Simple  weakness. 

2.  Injury  to  the  cord, 

3.  Tumors  of  the  cord. 

4.  Syphilitic  disease  of  the  cord. 

The  weakness  and  stiffness  caused  by  Pott's  disease  in  the  lower  region 
may  be  simulated  by  lumbago,  rheumatism,  sciatica,  and  by  the  effect  of 
injury  or  strain.  Lumbago,  rheumatism,  and  sciatica  are  uncommon  in 
childhood.     They  are  usually  of  sudden  onset.     Sciatica  is  usually  uni- 


Fig.   287. — Pott's  Disease.     Case  of  Harry  F.     (Original.) 


lateral;   the  pain  of  Pott's  disease  is  usually  bilateral.     Strains  and  other 
injuries  have,  as  a  rule,  a  well-defined  history. 

Prognosis. — This  should  be  cautiously  given.  "While  most  cases  seen 
by  me  ended  fatally,  several  cases  improved  and  recovered  entirely.  Years 
of  patient  treatment  are  necessary,  and  occasionally  the  most  severe  cases 
may  end  in  recovery. 

Harry  F.,  4  years  old. 

Family  Histori/. — Fatlier  and  mother  are  imhealthy,  weak  and  veiy  poor.  One 
child  has  died  of  summer  complaint.  Another,  two  years  yoimger,  is  inclined  to 
cough,  and  was  operated  by  me  for  empyema. 


854  DISEASES    OF    THE    SPINE    AND    JOINTS. 

Personal  History. — The  child  was  born  and  has  since  then  lived  in  a  tenement 
house,  in  a  densely  populated  section  of  the  city.  He  was  a  bottle-fed  infant,  and 
has  been  constipated  since  birth,  although  he  suffers  with  diarrhoea  in  summer. 
Has  always  been  a  frail  and  sensitive  child.  Has  had  measles  and  bronchitis,  and 
is  constantly  troubled  with  some  catarrhal  affection.  The  child  was  late  in  walking, 
late  in  talking,  and  late  in  dentition.  The  general  development  shows  backwardness 
when  compared  with  a  normal  child.  A  slight  deformity  of  the  spine  was  first 
noticed  when  the  child  was  about  2  years  old.  It  has  increased  in  prominence  since 
that  time.  There  is  no  distinct  evidence  of  tuberculosis  that  can  be  made  out  in  the 
lungs.  The  glands  are  not  enlarged,  there  is  no  cough  or  expectoration.  No  evidence 
of  fever. 

The  treatment  consisted  in  giving  codliver-oil  and  creosotal  internally  from  2 
to  5  drops,  three  times  a  day.  Friction  of  the  body  and  general  hygienic  measures 
were  instituted.  Great  stress  was  laid  on  the  nourishment  of  the  body.  Cream, 
butter,  eggs,  cereals,  and  vegetables  have  been  given  constantly. 

Orthopedic  Treatment. — For  the  relief  of  the  deformity,  a  supporting  brace 
fitted  to  the  body  like  a  corset,  similar  to  a  Bradford  frame,  had  been  used  for  over 
six  months  with  little  improvement,  therefore  the  case  was  sent  to  Dr.  Ashley  for 
a  plaster-of-Paris  corset.  This  treatment  has  been  very  successful,  and  the  child 
is  progressing  favorably. 

Treatment.  —  When  piis  is  present  nothing  but  surgical  treatment 
should  be  considered.  Surgical  treatment  is  not  always  necessary.  The 
majority  of  cases  require  support  by  means  of  (a)  spinal  splint;  (h)  spinal 
brace;  (c)  plaster  jacket. 

Either  of  these  must  be-  properly  applied  by  a  competent  surgeon.  I 
have  seen  some  very  disagreeable  accidents  due  to  a  too  tight  plaster  corset. 
For  details  in  connection  with  the  application  of  braces  or  plaster  jackets 
the  reader  is  referred  to  text-books  on  orthopsedic  surgery. 

Medicinal  Treatment. — This  consists  in  giving  restoratives  such  as 
codliver-oil,  iron,  and  arsenic.  Creosotal  can  be  given  with  the  codliver- 
oil.  A  rigid  diet  such  as  cream,  butter,  milk,  cereals,  eggs,  vegetables,  and 
fruits  is  indicated. 

If  the  child  lives  in  the  city  a  change  to  the  seashore  or  to  the  moun- 
tains will  sometimes  improve  the  chances  of  recovery, 

Flatfoot  in  Childken, 

Children  are  not  born  fiatfooted.  Very  heavy  children  are  predis- 
posed to  flatfoot,  especially  if  rickets  is  present.  Laxity  of  the  knees  is 
usually  found  associated  with  this  condition. 

Treatment. — Careful  orthopaedic  treatment  is  necessary.  This  usu- 
ally consists  in  wearing  a  properly  fitting  shoe  in  which  the  arch  is  sup- 
ported with  the  aid  of  a  stiff  steel  or  celluloid  plate.  At  times  a  soft  pad 
of  felt  only  is  necessary. 

E.  W.  Lovett,  of  Boston,  has  contributed  to  the  literature  of  this 
subject,  and  the  reader  is  referred  to  his  writings  for  details  on  this  matter. 


SCOLIOSIS.  855 

Spinal  Curvature. 

The  spine  of  a  new-born  infant  is  almost  straight,  but  from  the  time 
the  child  begins  to  walk  erect,  curvatures  arise  in  the  direction  forward 
and  backward  which  are  normal  and  physiological,  viz.,  a  curvature  with  the 
convexity  forward  in  the  region  of  the  neck,  backward  in  the  dorsal  region 
and  forward  in  the  lumbar  region. 

Kyphosis. 

Kyphosis  is  also  known  as  round-back.  It  is  an  increase  in  the  normal 
curvature  in  the  dorsal  region  of  the  spine.  It  is  a  non-inflammatory  con- 
dition and  is  amenable  to  treatment.  The  increase  in  the  curvature  back- 
ward is  called  round-back,  kyphosis  arcuata,  increase  in  the  curvature 
forward,  saddle-back,  lordosis.  The  cause  is  usually  faulty  position  assumed 
at  school  or  at  home,  and  associated  therewith  weakness  of  both  muscles 
and  bones. 

I  have  elsewhere  in  the  article  on  rachitis,  also  in  the  article  on  Pott's 
disease,  described  this  condition. 

The  treatment  depends  on  the  cause.  If  it  is  due  to  rachitis,  restorative 
treatment  is  indicated.  Iron,  hypophosphites  of  lime  and  soda,  and  codliver 
oil  are  the  drugs  to  be  given.  In  addition  to  drug  treatment,  fresh  air 
and  out-door  life  must  be  given  before  gymnastic  exercises  are  considered. 
Deep  breathing  with  arms  raised  and  extended  forward  and  backward,  in 
a  cool  room,  should  be  a  daily  routine.  Tlie  exercises  should  not  be  carried 
to  a  point  of  exhaustion;  usually  ten  to  fifteen  minutes  is  sufficient  to 
produce  a  good  reaction. 

If  the  kyphosis  is  due  to  tuberculosis  of  the  spine  an  open-air  life 
should  be  recommended.  The  treatment  of  tuberculosis  in  general  applies 
very  forcibly  to  Pott's  disease,  but  we  must  remember  that,  be  the  kyphosis 
due  to  an  atony  of  the  muscles  or  to  a  general  systemic  weakness  such  as 
rachitis,  such  cases  will  relapse  unless  the  daily  exercise  is  continued. 

Scoliosis. 

Every  permanent  deviation  to  the  side,  in  the  spine,  is  called  lateral 
curvature  or  scoliosis,  and  is  the  fonn  most  commonly  met  with  of  all 
deformities  of  the  spine. 

Scoliosis  may  be  called  cerv'ical,  dorsal,  or  lumbar  scoliosis,  depending 
upon  which  part  of  the  back  is  bent.  The  curvature  may  include  only  a 
few  vertebrce,  or  the  spine  in  its  entirety.  Two  or  more  cun^atures  may 
simultaneously  be  found  in  the  same  person.  Scoliosis  can,  further,  be 
right-sided  or  left-sided,  according  to  the  convexity  of  the  lateral  curvature. 

Scoliosis  has  a  pretty  constant  course.  Although  no  exact  limit  can 
be  fixed,  scoliosis  may  be  suitably  divided,  from  a  s}T2iptomatological  point 


856  DISEASES  OF  THE  SPINE  AND  JOINTS. 

of  view,  into  three  degrees  of  development.  The  slightest  forms  of  scoliosis 
can  develop  into  the  most  severe:  it  is  impossible,  however,  in  every  case 
to  foretell  whether  a  scoliosis  will  be  stationary  at  a  certain  stage  or  whether 
it  will  further  develop  itself. 

A  scoliosis  of  the  first  degree  may,  to  the  unpractised,  be  difficult  to 
detect,  as  no  clear  curvature  of  the  spine  can  be  observed.  The  existence  of 
the  scoliosis  is  characterized  by  a  slightly  forward  arching  or  bulging-out  of 
the  lateral  contour  in  the  region  of  the  chest.     Scoliosis  of  the  first  degree 


Fig.    288. — Scoliosis  due  to  faulty  Fig.    289. — Same  girl;  arms  folded.    Note 

posture   at   school.  difference  in  scapulae.      (Original.) 

is  noted  whenever  the  patient  takes  a  standing  or  sitting  position,  but  it 
disappears  in  a  hanging  or  lying  position.  A  scoliosis  of  the  second  degree 
can  also  disappear,  as  long  as  the  patient  takes  certain  positions  or  per- 
forms certain  movements  which  counteract  the  form  of  scoliosis  in  ques- 
tion; pressure  on  the  convexity  of  the  curvature  may  also  bring  the  spine 
back  to  a  straight  position.  A  scoliosis  of  the  first  degree  is  called  simple, 
primary,  or  C-formed.  G-enerally  the  primary  scoliosis  appears  as  a  right- 
convex  dorsal  scoliosis  or  as  a  left-convex  lumbar  scoliosis, 

A  scoliosis  of  the  second  degree  arises  in  the  following  manner:   that 
to  the  primary  curvature,  after  a  time,  another  unites  itself — a  secondary. 


SCOLIOSIS.  857 

compensatory  or  so-called  anti-curvature;  in  consequence  of  this  formation 
the  scoliosis  has  become  8-formed.  A  scoliosis  of  the  second  degree  differs 
also  from  one  of  the  first  degree  in  that  the  curvature  does  not  now  quite 
disappear  in  a  hanging  or  lying  position,  not  always  in  taking  certain  bodily 
positions,  nor  by  means  of  pressure  on  the  convexity  of  the  curvature,  but 
the  spine  is,  however,  still  mobile;  so  that  the  curvature  in  the  given  position 
is  diminished,  in  consequence  of  which  the  scoliosis  can  be  treated  success- 
fully also  in  this  stage. 

The  third  degree  of  development  in  scoliosis  is  arrived  at  by  the  for- 
mation of  several  deformities  of  the  spine  itself  and  of  the  adjacent  Ixjnes, 
whereby  the  scoliosis  becomes  permanent  or  -fixed,  po  that  the  curvature 
of  the  spine  itself  in  this  stage  cannot  be  treated.  The  attendant  symptoms 
of  shortness  of  breath,  disordered  circulation  and  intercostal  neuralgia  must, 
on  the  other  hand,  often  be  treated.  The  scoliosis  in  this  degree  is  called 
kypho-scoliosis. 

When  a  scoliosis  develops  itself,  the  vertebrce  undergo  a  most  radical 
change  from  a  pathological  point  of  view,  and  this  change  is  not  easy  to 
detect,  but  the  alterations  in  the  ribs,  with  respect  both  to  form  and  position, 
is  the  surest  symptom  from  a  purely  clinical  point  of  view. 

Through  the  uneven  pressure  to  which  the  vertebrae  are  exposed  in  a 
scoliotic  spine,  the  side  directed  toward  the  concavity  of  the  curvature  will 
be  slower  in  growth,  while  the  side  directed  toward  the  convexity  will  de- 
velop itself  normally.  The  consequence  of  different  development  will  be 
that  the  vertehne  will  gradually  assume  the  form  of  a  wedge,  with  the  point 
of  the  wedge  directed  toward  the  concave  side  of  the  scoliosis. 

From  a  clinical  point  of  view  the  greatest  change  is  to  be  found  in 
the  ribs,  so  that  an  incipient  scoliosis  is  most  easily  detected  in  the  change 
the  chest  undergoes  in  its  entirety.  The  special  alterations  in  the  ribs  ac- 
company those  of  the  vertebrae.  For  example*  those  ribs  that  correspond 
to  the  convexity  of  the  scoliosis  will  be  separated  from  each  other,  while 
those  that  correspond  to  the  concavity  will  become  compressed  and  even 
atrophic.  The  ribs  on  the  convex  side  will  develop  a  considerable  increased 
flexion  of  their  posterior  extremitj'^,  and  diminished  flexion  of  their  anterior 
extremity. 

A  change  of  position  of  the  sternum  does  not  so  frequently  occur,  but 
in  the  above-named  form  of  scoliosis,  in  some  cases,  the  lower  end  of  the 
sternum  deviates  toward  the  left,  i.e.,  toward  the  concavity  of  the  curvature. 

In  a  well-marked  scoliosis  the  pelvis  will,  in  consequence  of  the  uneven 
weighing,  also  be  crooked  and  asymmetrical,  especially  in  more  severe 
lumbar  scoliosis,  as  then  the  os  sacrum  also  takes  part  in  the  spinal 
curvature. 

As  regards  the  muscles  of  the  spine,  the  change  in  the  same  was  for- 
merly considered  to  be  very  considerable,  and  it  has  even  been  considered 


858  DISEASES  OF  THE  SPINE  AND  JOINTS. 

as  being  the  origin  of  the  scoliosis.  In  well-marked  scoliosis  the  long  dorsal 
muscles  that  run  over  the  convexity  of  the  curvature  become  stretched  and 
even  atrophic,  perhaps  mostly  in  consequence  of  the  rigidity  of  the  spine 
and  the  consequent  inactivity  of  the  muscles. 

The  shoulder-hJade  is  removed  from  its  normal  position  by  the  change 
in  the  chest.  The  shoulder-blade  on  the  convex  side  is  pushed  forward 
by  the  increased  posterior  bulging  out  of  the  ribs  in  the  direction  upward, 
backward  and  outward  from  the  middle  line ;  the  shoulder-blade  on  the  con- 
cave side  sinks,  because  the  ribs  on  this  side  will  be  less  curved  posteriorly, 
and  the  shoulder-blade  draws  nearer  to  the  middle  line. 

When  muscular  weakness  due  to  faulty  nutrition  exists,  we  have  a 
predisposition  which  asserts  itself  in  a  faulty  posture,  such,  for  instance, 
as  an  incorrect  writing  position  or  various  kinds  of  female  handwork. 
Infantile  paralysis,  by  virtue  of  its  arrested  development,  will  cause  a 
shortening  of  the  affected  leg,  and  thereby  be  a  factor  in  the  development 
of  a  spinal  curvature  in  the  lumbar  region.  In  children,  faulty  position  in 
standing,  as,  for  example,  standing  on  one  leg  or  sitting  so  that  the  body 
weight  rests  on  one  buttock,  is  a  conmion  cause  of  lumbar  scoliosis.  Eulen- 
burg  states  that  rachitic  scoliosis  is  found  in  50  per  cent,  of  cases  during 
the  second  year  of  life,  25  per  cent,  during  the  third  year,  and  from  the 
fourth  year  a  decrease  down  to  the  sixth  year.  When  a  general  rachitis 
exists  or  when  we  note  the  presence  of  a  pigeon-breast  or  a  funnel-shaped 
breast,  in  such  children  one  is  likely  to  meet  with  a  rachitic  scoliosis. 
Pleurisy  with  effusion  is  another  cause  of  scoliosis.  If  the  effusion  remains, 
or  results  in  a  pj'Othorax  from  the  shrinking  of  the  lung  and  sinking  of 
the  diseased  half  of  the  chest,  there  will  result  a  scoliosis  in  the  dorsal 
region,  having  the  concavity  toward  the  healthy  side. 

A  radiograph  is  the  most  exact  method  of  recording  the  curvature,  and 
studj^ing  the  therapeutic  results. 

Prophylaxis. — In  the  very  young  child  it  is  almost  impossible  to  prevent 
scoliosis  when  the  bodily  structure  is  weak,  as  in  rachitis.  In  the  older 
child,  where  the  effects  of  faulty  position  in  sitting  or  standing  can  be 
explained,  it  is  frequently  possible  to  prevent  scoliosis. 

Girls  between  the  ages  of  8  and  15,  especially  those  who  desire  to 
shine  by  contrast  in  societj',  are  frequently  overburdened  with  home-work, 
needle-work,  painting  or  piano  practice  which  frequently  requires  hours  of 
patient  sitting.  It  is  this  class  of  cases  in  which,  by  overstrain,  the  spine 
is  weakened  and  curvature  results. 

Treatment. — Only  simple  curvatures,  or  those  resulting  from  weak 
muscles,  faulty  habits  or  position  shall  be  considered.  Curvatures  resulting 
from  congenital  or  pathologic  anomalies,  caries  of  the  spine,  tuberculosis, 
etc.,  should  be  sent  to  the  orthopedist. 

Begin  with  good  breathing  exercises.    Train  the  habit  of  posture.    Give 


PLATE  XLTTT 


X-ray  of  Congenital  Dislocation  of  Hip. 


SCOLIOSIS. 


859 


genei-al  liglit  exercises  for  muscle  building  and  stimulation  of  the  circulation, 
respiration,  and  digestion. 

It  is  impossible  to  lay  down  rules  which  can  apply  to  every  case  of 
scoliosis.  Thus,  a  scoUmis  of  the  first  degree  will  do  very  well  by  strictly 
supervising  and  preventing  the  faulty  position  while  at  school  or  at  home. 
In  addition  tlieix'to,  g3'ninastic  exercises  to  develop  and  strengthen  the 
muscles  of  the  h-dvk  and  chest  will  quickly  solve  tin's  problem.  In  addition 
to  the  niechanienl  treatment,  restoratives  such  as  iron,  hypophosphites,  and 


Fig.  2UU. — in  cervical  scoliosis,  sicie 
flexion  in  the  region  of  the  neck  can 
best  be  obtained  by  having  a  boom  or 
crutch  placed  under  the  arm-pit,  at  a 
height  to  obtain  a  firm  support.  This 
position  should  be  retained  from  three 
to  five  minutes. 


Fig.  2!)1. — Exercise  adapted  for 
lateral  curvature.  Patient  sits  on  a 
stool  in  such  a  manner  that  the  anterior 
bent  leg  rests  on  the  floor,  while  the 
whole  of  the  buttocks  and  the  upper  leg 
rests  on  the  stool.  This  position  is 
maintained  while  ten  to  twenty  deep 
breaths  are  drawn. 


codliver  oil  should  be  given.  Eresh  air  and  out-door  exercises  should  form 
the  basis  for  the  tonic  which  will  help  to  assimilate  food  and  thus  strengthen 
the  bone  and  muscle. 

A  scoliosis  of  the  second  degree  or  scoliosis  of  the  third  degree  requires 
not  only  the  restorative  treatment  above  mentioned,  but,  in  addition 
thereto,  mechanical  treatment.  Such  mechanical  treatment  consists  in  the 
temporary  support  given  to  the  spine  by  plastei'-of-Paris  cast,  or,  in  many 
cases,  the  cui'vature  can  be  corrected  with  the  aid  of  a  spinal  brace.  Such 
brace  or  plaster-of-Paris  support  is  utilized  to  correct  the  curvature,  an(i 


860 


DISEASES  OF  THE  SPINE  AND  JOINTS. 


when  the  mechanical  appliance  is  removed  gymnastic  exercises  are  given  to 
restore  the  tone  of  the  muscles  and  aid  in  the  circulation  which  is  disturbed 
while  the  mechanical  appliance  is  used.  The  gymnastic  treatment  should  be 
supported  by  massage. 

Hanging  is  especially  indicated  in  cases  of  kyphosis.  The  spine  and 
spinal  muscles  are  stretched  into  their  normal  position  by  the  weight  of 
the  patient's  body. 


Fig.  292. — Sitting-han-ging  with  rod 
is  principally  used  for  round-back,  but 
also  to  advantage  in  scoliosis.  The 
nurse  stands  behind  the  patient  and 
offers  slight  resistance  to  the  rod  as  the 
patient  stretches  his  arms,  and  resist- 
ance is  still  offered  when  the  arm  ex- 
tension has  reached  its  maximum,  so 
that  the  patient  is  obliged  to  keep  a 
stretched  and  corrected  bearing  of  the 
body.  This  position  should  be  main- 
tained from  one-fourth  to  one-half  min- 
ute.    Eepeat  ten  to  fifteen  times. 


Fig.  293. — Resistance,  especially 
adapted  for  young  children.  The  pa- 
tient places  his  hands  in  the  groin  with 
the  four  fingers  together  forward,  the 
thumbs  directed  backward,  thus,  by 
putting  the  extensors  of  the  arms  into 
action,  causing  a  lifting  of  the  trunk, 
while  stretching  takes  place  at  the 
same  time  in  the  spine.  The  mother  or 
nurse  stands  at  the  side  of  the  patient 
and  sees  that  he  carries  his  shoulders 
backward  as  far  as  possible;  slight 
pressure  in  the  middle  of  the  back  and 
over  the  crown  of  his  head  encourages 
still  greater  exertion,  i.e.,  the  move- 
ment is  changed  from  a  purely  active 
one  to  a  movement  of  resistance.^ 


^  I  am  indebted  to  Dr.   Anders   Wide's   Hand-book  of  Medical   and  Orthopaedic 
Gymnastics,  published  by  Funk  &  Wagnalls,  for  the  illustrations  in  this  article. 


HIP-JOINT  DISEASE.  861 

The  hands,  separated  from  each  other  by  the  width  of  the  shoulders, 
take  hold  of  the  pole  or  trapese,  placed  or  held  at  such  a  height  that  the 
feet  do  not  touch  the  ground  when  the  arms,  trunk,  and  legs  are  fully 
extended. 

With  heels  together  and  knees  straight,  have  patient  bend  body  for- 
ward until  the  hands  touch  the  floor  in  front  of  the  toes,  or  come  as  near 
to  the  floor  as  possible,  then  raise  the  body  to  standing  position.  Eepeat 
slowly  ten  to  fifteen  times. 

Abbott^  and  others  have  advised  an  overcorrection  of  the  curvature  to 
secure  normal  conditions.  Many  orthopedists  have  told  me  that  while  this 
is  a  painful  method  it  has  its  advantages.  Others  have  advised  against  the 
overcorrection.  The  method  seems  best  adapted  for  the  very  young  where 
marked  elasticity  of  the  spinal  column  still  exists. 

Morbus  Coxarius  (Hip- joint  Disease;  Tubercular 
Hip-joint  Disease). 

Coxitis,  commonly  known  as  tuberculosis  of  the  hip-joint,  is  not  easily 
diagnosticated  in  the  primary  stage. 

The  age  is  no  hindrance  to  the  development  of  this  disease,  as  it 
usually  appears  between  the  fifth  and  tenth  years. 

Coxitis  can  be  found  in  apparently  healthy  children  showing  no  sign 
of  scrofulosis. 

1.  They  complain  of  tenderness. 

2.  Impediment  of  locomotion  of  the  affected  extremity. 

3.  The  change  of  the  position. 

4.  Local  changes  in  the  region  of  the  joint. 

Symptoms. — The  pain  is  one  of  the  earliest  symptoms  and  expresses 
itself  by  a  feeling  of  tenderness  in  the  affected  joint  or  in  the  knee. .  The 
knee  is  quite  characteristic  in  this  affection  and  serves  a  good  center  for 
deception.  In  the  knee  no  changes  are  directly  noticeable;  there  is  no 
impediment  to  locomotion.  When  the  pain  can  be  located  in  the  knee- 
joint  the  pathological  process  in  the  hip-joint  is  usually  fully  developed. 
When  children  complain  of  pain  in  the  knee-joint,  it  is  always  wise  to 
examine  the  hip.  One  of  the  most  characteristic  symptoms  is  the  in- 
variable cry  at  night. 

The  child  will  cry  frequently  and  will  suddenly  awaken  at  night,  tviih 
pain  along  the  thigh  not  pointing  to  a  distinct  spot,  hut  showing  that  the 
pain  is  diffused  along  the  leg;  this  symptom  is  rarely  absent  in  true 
coxitis. 


^Abbott,  N.  Y.  Medical  Journal,  April  27,  1912. 


862 


DISEASES  OF  THE  SPINE  AND  JOINTS. 


At  the  earliest  stage  of  coxitis  tlie  pain  is  trivial^  but  instinctively 
the  patient  tries  to  use  the  healthy  limb  and  not  the  unhealthy  one.  This 
is  one  of  the  causes  of  limping.  When  tenderness  can  actually  be  located, 
then  locomotion  is  also  limited.  When  this  exists,  difficulty  in  abduction 
and  adduction  appears. 

When  examining  by  grasping  the  affected  limb  with  one  hand  and 
supporting  the  small  of  the  back  with  the  second  hand,  a  distinct  resistance 
of  the  muscles  can  be  felt. 


Fig.    294. — Tuberculous  Coxitis — Front 
View. 


Fig.    295. — Tuberculous   Coxitis- 
View. 


-Side 


TUEEKCULOUS    COXITIS     (DOUBLE). 

C.  M.,  10  years  old,  girl.  Duration  of  disease,  in  left  hip  six  years,  a,nd 
right  hip  five  years.  No  history  of  exanthematous  diseases.  Treated  at  the  Post- 
graduate for  seven  months  in  orthopedic  ward.  An  erasion  of  disease  in  left  hip 
at  this  time. 

Examination. — Right  hip  flexed  to  90°,  left  hip  flexed  to  about  95°.  Right  hip 
in  adduction  10°,  distinct  spasm  of  the  adductor  muscles.  Left  hip  in  adduction  35°, 
slight  spasm  of  the  adductor  muscles.  Motion  in  right  hip  10°,  in  left  hip  20°. 
Right  great  trochanter  two  inches  above  Nelaton's  line.  Apparently  no  abscesses. 
Left  trochanter  almost  denuded  by  erasion,  only  slightly  above  Nelaton's  line. 
Many  abscess  scars,  all  healed. 

Treatment. — ^Modified  Gant  on:  right  side,  forcible  correction  of  the  left  side, 
with  tenotomies. 


Congenital  Dislocation  of  the  Hip. 

This  is  the  most  frequent  form  and  the  most  important  of  the  con- 
genital dislocations. 

Illustrations   Figs.   294   and   295    are   furnished   through   the   courtesy   of   Dr. 
Dexter  Ashley. 


CONGENITAL  DISLOCATION  OF  THE  HIP.  863 

Etiology.— Faulty  development  of  the  acetabulum  and  the  head  of 
the  femur  combined  with  laxity  of  the  capsule  and  possibly  pressure  upon 
the  flexed  thigh  are  supposed  to  be  the  causes  of  this  condition.  The  dis- 
placement is  usually  upon  the  dorsum,  although  it  may  take  place  forward 
or  upward.  It  is  most  frequent  in  females.  Whitman  states  that  85  per 
cent,  occur  in  females.  It  is  usually  seen  unilateral.  I  have  seen  many 
cases  bilateral.  Sometimes  a  peculiar  family  predisposition  seems  to  exist, 
as  several  children  in  the  same  family  have  this  deformity. 


Fig.    296. — Congenital  Hip  Dislocation.     Cases  occurred  in  the  practice  of 

Dr.  Dexter  Ashley. 

Symptoms. — Unilateral  Dislocation.. — 'The  child  limps  when  it  begins 
to  walk.  The  abdomen  is  very  prominent.  There  is  an  abnormal  lordosis. 
The  buttocks  appear  enlarged.  The  thighs  are  usually  separated  and  there 
is  an  increased  breadth  of  pelvis.  Shortening  is  difficult  to  detect  in  the 
beginning  of  the  disease,  but  if  the  child  groAvs  older  and  the  condition 
has  been  neglected,  then  a  shortening  of  several  inches  may  sometimes  be 
detected.     Such  children  are  easily  fatigued. 

Bilateral  Dislocation. — The  pelvis  is  broadened  and  the  thighs  are  far 
apart  when  the  patient  stands  or  walks.  The  limp  is  exaggerated  and  the 
child  waddles.    The  lordosis  is  very  marked. 


864  DISEASES  OF  THE  SPINE  AND  JOINTS. 

Treatment. — Eeplacement  by  traction,  by  extreme  abduction  and 
flexion  with  prolonged  fixation  in  the  attitude  of  extreme  abduction,  known 
as  the  Lorenz  treatment,  is  frequently  successful.  In  some  cases  the 
above  treatment  is  unsuccessful  and  a  radical  operation  must  then  be 
performed. 

G.  L.,  male,  9  years  old;  A.  L.,  female,  6  years  old;  H.  L.,  female,  4  years  old. 
Three  out  of  five  children  in  one  family,  of  Irish  parentage.  No  previous  history 
of  lameness. 

G.  L.,  double  posterior  dislocation;  muscular;  great  telescopic  motion;  right 
side  has  a  shortening  of  2^  inches,  left  side  2%  inches,  as  per  Nelaton's  line;  head 
and  neck  apparently  well  developed ;  thighs  flexed,  adducted  and  rotated  inward ; 
marked  lordosis;  walking  ungainly  and  laborious;  limited  motion  in  abduction 
and  extension;  feet  inclined  to  be  flat;  can  stand  in  almost  normal  position  except 
lordosis.  Skiagraph  reveals  very  well-developed  neck  on  each  side,  the  right  inclined 
to  coxa  varus;  head  on  each  side  inclined  to  be  conical;  acetabula  rather  shallow, 
but  well  formed  otherwise.  Advised  no  operation  as  the  child  was  too  old,  and  the 
circumstances  of  the  family  would  not  admit  of  good  after-treatment. 

A.  L.,  right  posterior  dislocation;  distinct  limp;  limb  carried  slightly  in  ad- 
duction; shortening  IVo  inches;  neck  short  and  straight,  or  coxa  valgus.  Skiagraph 
verifies  above  observations,  and  shows  an  apparently  poorly  formed  acetabulum,  with 
considerable  thickening.  Preternatural  mobility  in  all  directions  except  abduction. 
Operation  advised  and  performed.     Transposition   secured. 

H.  L.,  4  years  old;  posterior  dislocation;  %  inch  shortening;  limp  well 
marked;  neck  and  head  rather  short  but  of  normal  angle;  preternatural  mobility  in 
all  directions  except  abduction.  Skiagraph  reveals  short  head  and  neck,  apparently 
well-formed  acetabulum.  Operation  performed.  Very  good  result,  but  might  have 
been  improved  upon  if  child  had  been  brought  in  for  after-treatment. 


Knee-joint  Disease. 

This  is  a  chronic  tuberculous  inflammation  due  to  an  osteitis  of  the 
femur  or  tibia.     It  may  begin  as  a  synovitis  similar  to  hip-joint  disease. 

Etiology. — Traumatism  is  usually  the  exciting  factor,  as  in  hip-Joint 
disease. 

Pathology. — The  pathological  lesions  are  those  of  tuberculosis.  The 
tubercle  bacillus  is  usually  found,  although  it  may  be  absent.  The  lesions 
spread  and  sometimes  cause  complete  destruction  of  the  joint.  A  char- 
acteristic swelling  noted  in  tuberculous  knee-joint  is  caused  by  an  infiltra- 
tion of  the  soft  parts  with  a  gelatinous  substance  which  must  be  attributed 
to  a  tuberculous  process. 

Symptoms. — Children  old  enough  to  complain  will  describe  pain  when 
moving  the  joint.  A  limp  is  noticed  when  walking.  A  swelling  of  the 
joint  gradually  appears.  The  knee  assumes  a  flexed  appearance  which  is 
quite  typical  of  this  condition.  As  a  result  of  the  swelling  in  the  joint, 
motion  is  limited,  and  the  pain  at  times  is  very  severe.  Fever  may  or  may 
not  be  present.    In  a  ease  seen  by  me  recently,  although  a  large  quantity 


WRIST-JOINT  AND  ELBOW-JOINT  DISEASE.  865 

of  pus  was  present,  no  fever  could  be  detected.  This  condition  was  one  of 
the  usual  "cold  abscess  type." 

Diagnosis. — ^This  depends  on  the  limitation  of  motion,  on  the  swell- 
ing, and  on  the  pain.  It  does  not  resemble  rheumatism  owing  to  the  affec- 
tion being  limited  to  one  joint.  In  rheumatism  there  is  fever,  at  times 
very  high  fever,  inflammation,  swelling,  and  a  sudden  onset  of  symptoms. 
Just  the  reverse  condition  is  found  in  knee-joint  disease. 

Prognosis. — The  prognosis  as  a  rule  is  good.  Fully  90  per  cent,  of 
cases  recover,  according  to  Moore.  When,  however,  cases  are  neglected, 
ankylosis  of  the  knee-joint  results. 

Treatment. — Eest  in  bed,  assisted  by  proper  hygiene  and  a  good  sup- 
porting diet,  constitute  the  general  line  of  treatment  to  be  pursued  by  the 
general  practitioner.  The  deformity  requires  careful  orthopaedic  treat- 
ment. A  case  of  this  kind  usually  requires  a  knee-splint  or  a  plaster  cast. 
It  is  self-understood  that  only  one  competent  to  do  this  should  guide  the 
treatment.  For  details  regarding  the  application  of  knee-splints,  etc.,  the 
reader  is  referred  to  works  on  orthopaedic  surgery. 

Diseases  of  thei  Ankle- joint  and  Taesds. 

Tubercular  disease  frequently  affects  the  ankle  and  tarsus.  The  same 
pathological  manifestations  described  in  hip  and  knee-joint  diseases  are 
found  here. 

Symptoms. — As  a  rule  a  limp  will  be  noticed.  Associated  with  this 
there  is  swelling  of  the  joint,  limitation  of  motion,  and  in  some  cases  fever ; 
in  other  cases,  atrophy  of  the  muscles  of  the  leg.  The  superficial  veins  are 
usually  enlarged. 

Diagnosis. — The  slow  onset  of  the  symptoms  associated  with  swelling 
and  the  limp  on  walking  will  usually  aid  in  establishing  the  diagnosis. 
It  is  important  to  exclude  rheumatism  by  carefully  examining  other  joints 
of  the  body.  The  diagnosis  rests  upon  the  disease  being  limited  to  one 
joint  in  addition  to  the  symptoms  above  described. 

Prognosis. — The  prognosis  is  usually  good.  Cases  usually  recover 
under  proper  management  in  six  to  nine  months. 

Treatment. — ^The  samei  treatment  described  in  the  article  on  knee- 
joint  disease  applies  here.  The  parts  should  be  given  absolute  rest.  This 
can  be  secured  by  the  use  of  plaster-of-Paris  casts.  The  rest  of  the  treat- 
ment is  restorative. 

Wrist-joint  and  Elbow-joint  Diseases. 

This  condition  is  rarely  met  with  in  children.  When,  however,  tuber- 
culous manifestations  exist  the  symptoms  are  the  same  as  described  in 
other  tubercular  joints. 


866 


DISEASES    OF    THE    SPINE   AND    JOINTS. 


Treatment  consists  in  securing  rest  and  immobility  of  the  parts  with 
the  aid  of  plaster  casts.  Pus,  when  present,  requires  surgical  relief.  The 
outcome  of  these  cases  is  as  a  rule  good. 

Joseph  S.,  10  years  old,  has  been  under  the  treatment  of  Dr.  Dexter  Ashley,  to 
whom  I  am  indebted  for  the  illustration.  The  child  was  in  an  extremely  ansemic 
condition,  heart  and  lungs  normal,  no  evidence  of  tuberculosis.  Family  history  good. 
Local  evidence  of  tuberculosis  involving  the  elbow-joint,  so-called  bone  tuberculosis. 
The  boy  was  able  to  run  about,  and  excepting  this  arm  seemed  to  be  in  a  fair  physical 


Fig.    297. — Tubercular  Elbow-joint. 

condition.  A  comparison  of  the  healthy  elbow-joint  with  the  diseased  joint  is  quite 
interesting.  Dr.  Ashley's  treatment  consisted  in  strict  aseptic  dressings,  tight 
bandaging,  a  bandage  to  support  the  return  circulation,  and  general  restorative  treat- 
ment. 


Acute  Arthritis  (Infectious  Osteitis:    Acute  Purulent  Synovitis: 
Acute  Epiphysitis:    Acute  Osteomyelitis). 

This  is  an  acute  inflammator}^  condition  involving  a  joint.  It  is 
always  suppurative  from  the  beginning;  it  is  therefore  a  form  of  pyaemia. 
It  is  an  infection  originating  at  the  bone  in  the  medullary  canal  or  in  the 
joint. 


ACUTE  ARTHRITIS.  867 

Etiology. — This  condition  may  follow  the  acute  infectious  diseases, 
especially  those  which  show  a  tendency  to  suppurative  processes.  It  most 
frequently  follows  measles,  scarlet  fever,  and  empyema. 

There  seems  to  be  no  reason  to  believe  that  this  disease  owes  its  exist- 
ence to  syphilis,  tuberculosis,  or  scrofulosis.  Some  authors  state  that  a 
history  of  traumatism  has  preceded  this  infectious  disease. 

Bacteriology. — Cultures  taken  of  the  purulent  discharge  usually  show 
the  presence  of  the  streptococcus  pyogenes  or  the  staphylococcus.  The 
point  of  entrance  for  the  pathogenic  bacteria  may  be  either  the  skin,  if 
abraded,  the  umbilicus,  or  the  tonsil.  In  this  manner  the  bacteria  gain 
entrance  to  the  circulation. 

Symptoms. — Distinct  swelling  of  the  joint  can  be  made  out,  although 
the  inflammatory  condition  is  deep-seated.  The  joint  is  red  and  inflamed 
and  has  a  glazed  appearance.  Fluctuation  can  be  felt  if  properly  palpated. 
The  usual  symptoms  of  inflammation,  such  as  high  fever  and  chills  or 
rigors,  are  present. 

The  joints  most  usually  affected  are  best  judged  by  studying  Town- 
send's  collection  of  cases: — 

Hip    38  cases 

Knee   27  cases 

Shoulder  12  cases 

Wrist    5  cases 

Elbow   4  cases 

Ankle    4  cases 

Fingers  - 2  cases 

Toes    1  case 

Sternoclavicular 1  case 

Diagnosis  and  Differential  Diagnosis. — ^The  diagnosis  is  easily  made  if 
we  remember  the  rapidity  with  which  this  condition  develops.  It  may 
resemble  rheumatism,  but  the  acute  onset  with  the  fever  and  the  suppura- 
tion makes  it  easy  to  exclude  rheumatism.  Syphilis  may  resemble  arthritis, 
but  the  fever  and  suppuration  are  never  present  in  syphilis. 

Prognosis. — If  the  disease  extends  rapidly  death  may  occur  in  a  few 
days.  The  outcome  of  the  case  depends  on  recognizing  the  disease  in  its 
early  stages,  and  on  the  rapidity  with  which  the  suppurative  condition  is 
relieved. 

Treatment. — The  treatment  is  surgical.  With  aseptic  care  and  atten- 
tion to  surgical  detail,  pus  should  be  evacuated  and  the  joint  properly 
immobilized.  To  prevent  deformity  fixation  of  the  joint  should  be  remem- 
bered. Restorative  treatment  should,  consist  in  giving  arsenic,  maltine  with 
hypophosphites,  in  addition  to  concentrated  food  and  general  hygienic  care. 
The  surgical  treatment  should  be  given  into  the  hands  of  a  surgeon. 


PART  XII. 

MISCELLANEOUS. 


CHAPTER  I. 

DIETAKY. 

Bevebages. 

Albumin  Water. — Stir  the  whites  of  2  eggs  into  %  pJnt  of  ice-water, 
without  beating;  add  enough  salt  or  sugar  to  make  it  palatable.  Such  a 
mixture  is  one  of  the  best  foods  we  hare  for  substitute  feeding  an  infant 
with  digestive  disturbances  when  we  wish  to  temporarily  stop  all  milk-food. 

Almond-milk. — Take  two  ounces  of  sweet  almonds,  scald  them  with  boil- 
ing water;  after  a  few  moments  express  them  from  the  hulls;  then  pour  the 
hot  water  away.  Put  the  blanched  ahnonds  into  a  mortar  and  pound  them 
thoroughly,  and  add  either  2  ounces  of  milk  or  2  ounces  of  plain  water. 
After  this  is  thoroughly  mixed,  it  is  to  be  strained  through  cheese-cloth, 
and  the  strained  liquid  will  be  the  almond-milk. 

Arrowroot  Water. — Add  2  tablespoonfuls  of  arrowroot  to  1  pint  of 
water ;  allovr  it  to  simmer  for  half  an  hour,  stirring  it  constantl}^ 

Barley  Water. — Take  a  tablespoonful  of  pearl  barley,  grind  it  in  a 
coffee-grinder,  or  pound  it  in  an  ordinary  mortar;  add  1  quart  of  cold 
water,  and  allow  it  to  simmer  slowly  for  about  an  hour.  Strain  and  add 
enough  water  to  make  .1  quart. 

Beef  Juice. — Expressed  beef  juice  is  obtained  by  slightly  broiling  a 
j)iece  of  lean  beef  and  expressing  the  juice  with  a  lemon-squeezer.  One 
pound  of  steak  yields  2  or  3  ounces  of  juice.  This  is  flavored  with 
salt  and  given  cold  or  warm.  Do  not  heat  enough  to  coagulate  the  albumin. 
This  is  very  nutritious  and  usually  well  taken.  It  may  be  given  at  the 
rate  of  a  tablespoonful  three  times  a  day. 

Cocoa.^ — For  each  large  cup  take  a  teaspoonful  of  cocoa  and  a  tea- 
spoonful  of  sugar;  mix  to  a  paste  with  a  little  boiling  water  or  milk;  add 
balance  of  milk  or  milk  and  water,  as  richness  is  desired.  Let  it  boil  a 
minute,  as  boiling  improves  it. 

Chocolate  (Unsweetened), — Eor  each  breakfastcup  take  1  division, 
break  in  small  pieces,  and  allow  to  melt;  add  milk  or  milk  and  water,  as 


^  A  palatable  and  digestible  form  of  cocoa  is  mamifactured  by  Hershey,  of 
Pennsylvania. 

(868) 


DIETARY.  869 

richness  is  desired.  Stir  constantly.  Bring  to  a  boiling  point  and  set 
aside  to  simmer.     Sugar  to  taste. 

Eggnog. — Heat  some  milk  to  a  temperature  of  150°  F.,  but  do  not 
allow  ike  inilk  to  boil.  When  cold,  beat  up  a  fresh  egg  with  a  fork  in  a  tum- 
bler with  some  sugar;  beat  to  a  froth,  add  a  dessertspoonful  of  brandy,  and 
iill  up  tumbler  with  the  warm  milk. 

Oatmeal  Water. — Take  a  tablespoonful  of  ordinary  oatmeal,  and  add 
1  pint  of  water.  Allow  it  to  simmer  slowly  for  one  hour  and  strain.  Add 
enough  water  to  make  1  pint.  The  same  directions  apply  to  making  a 
household  mixture  of  farina-water,  and  sago-water,  using  the  same  propor- 
tions as  above. 

Rice  Water. — One  ounce  of  well-washed  Carolina  rice.  Macerate  for 
three  hours  at  a  gentle  heat  in  a  quart  of  water,  and  then  boil  slowly  for 
an  hour  and  strain.  It  may  be  sweetened  and  flavored  v/ith  a  little  lemon- 
peel.  Useful  in  diarrhoea,  etc.,  when  the  flavoring  is  best  dispensed  with, 
and  a  little  old  cognac  added. 

Yolk  of  Egg  Lemonade. — Take  the  beaten  yolk  of  1  egg  and  add  to 
it  the  juice  of  ^/g  lemon.  Let  stand  five  minutes,  thus  drawing  off  the  raw 
taste  of  the  yolk  of  egg.    Add  1  teaspoonful  of  sugar  and  8  ounces  of  water. 

White  of  Egg  Orangeade. — Take  the  juice  of  1  orange  and  1  ounce 
of  water,  insert  an  egg  whisk,  and  when  the  orangeade  is  in  full  agitation, 
add  slowly  the  white  of  egg.  Continue  the  whisking  for  two  or  three  min- 
utes more.     Add  14  teaspoonful  of  sugar. 

White  of  Egg  Lemonade. — Leftwich^  advises  the  following  for  a  nutri- 
tive drink  for  febrile  and  wasting  diseases : — 

IJ  Lemons   , 2 

White  of  eggs 2 

Boiling   water 1  pint 

Loaf  sugar  to  taste. 

The  lemon  must  be  peeled  twice — the  yellow  rind  alone  being  utilized 
— ^while  the  white  layer  is  rejected. 

Place  the  sliced  lemon  and  the  yellow  peel  in  a  quart  jug  with  2  lumps 
of  sugar.  Pour  upon  them  the  boiling  water  and  stir  occasionally.  When 
cooled  to  the  ordinary  temperature,  strain  off  the  lemons. 

Now  insert  an  egg  whisk,  and  when  the  lemonade  is  in  full  agitation 
add  slowly  the  white  of  egg.  Continue  the  whisking  for  two  or  three 
minutes  more.     While  still  hot,  strain  through  muslin.     Serve  when  cold. 

The  white  of  egg  will  be  found  to  impart  a  blandness  which  makes 
the  addition  of  sugar  almost  unnecessary. 

This  drink  is  very  useful  in  the  febrile  diseases  of  children.  It  may 
be  given  simply  as  a  lemonade,  without  mentioning  the  eggs,  and  will 

*  Edinburgh  Medical  Journal. 


870  MISCELLANEOUS. 

thus  be  readily  taken  by  the  children  and  difficult  patients.  It  also  pos- 
sesses antiscorbutic  properties,  which  replace  those  lost  from  milk  by  boil- 
ing and  sterilizing. 

Soups  and  Broths. 

Chicken  Broth. — Cut  up  a  small  chicken,  put  bones  and  all,  with  a 
sprig  of  parsle}^,  salt,  1  tablespoonful  of  rice,  and  a  crust  of  bread,  in  a 
quart  of  water  and  boil  for  one  hour,  skimming  it  from  time  to  time. 
Strain  through  a  coarse  colander. 

Keller's  Malt  Soup. — Take  of  wheat-flour  50.0  (about  2  ounces).  To 
this  add  11  ounces  of  milk.  Soak  the  wheat-flour  thoroughly,  and  rub  it 
through  a  sieve  or  strainer. 

Put  into  a  second  dish  20  ounces  of  water,  to  which  add  3  ounces  of 
malt  extract;  dissolve  the  above  at  a  temperature  of  about  120°  F.,  and 
then  add  10  cubic  centimeters  (about  2  ^/^  drachms)  of  11  per  cent,  potas- 
sium bicarbonate  solution.  Finally  mix  all  of  the  above  ingredients,  and 
boil. 

This  gives  a  food  containing: — 

Albuminoids   2.0  per  cent. 

Fat    1.2  per  cent. 

Carbohydrates   12.1  per  cent. 

There  are  in  this  mixture: 

Vegetable  proteids   0.9  per  cent. 

The  wheat-flour  is  necessary,  as  otherwise  the  malt  soup  would  have 
a  diarrhoeal  tendency.  The  alkali  is  added  to  neutralize  the  large  amount 
of  acid  generated  in  sick  children.  Biedert  emphasizes  the  importance  of 
giving  fat,  rather  than  reducing  its  quantity,  in  poorly  nourished  children, 
and  cites  the  assimil  ability  of  his  cream-mixture  or  of  breast-milk  in  under- 
fed children  as  proof  of  his  assertions.  The  author  has  used  this  malt 
soup  most  successfully  in  the  treatment  of  athrepsia  (marasmus)  cases  in 
which  the  children  were  simply  starved. 

Mutton  Soup. — Cut  up  fine  2  pounds  of  lean  mutton,  without  fat  or 
skin.  Add  1  tablespoonful  of  barley,  1  quart  of  cold  water,  and  a  teaspoon- 
ful  of  salt.  Let  it  boil  slowly  for  two  hours.  If  rice  is  used,  in  place  of 
barley,  soak  the  rice  in  water  over  night,  if  it  is  to  be  boiled  in  the  morning. 

Oyster  Broth. — Cut  into  small  pieces  1  pint  of  small  oysters ;  put  them 
into  ^/o  pint  of  cold  water,  and  let  them  simmer  gently  for  ten  minutes 
over  a  slow  fire.     Skim,  strain,  and  add  salt. 

White  Celery  Soup. — Take  ^/o  pint  of  strong  beef -tea;  add  an  equal 
quantity  of  boiled  milk,  slightly  and  evenly  thickened  with  flour.  Flavor 
with  celery  seeds  or  pieces  of  celery,  which  are  to  be  strained  out  before 
serving.  "  Salt  to  taste. 


DIETARY.  871 

Puddings  and  Desserts. 

Calf's-foot  Jelly. — Thoroughly  clean  2  feet  of  a  calf,  cut  into  pieces, 
and  stow  in  2  quarts  of  water  until  reduced  to  1  quart;  when  cold,  take  off 
the  fat  and  separate  the  jelly  from  the  sediment.  Then  put  the  jelly  into 
a  saucepan,  with  the  shells  and  whites  of  4  eggs  well  mixed  together ;  boil 
for  a  quarter  of  an  hour,  cover  it,  and  let  it  stand  for  a  short  time,  and 
strain  while  hot  through  a  flannel  bag  into  a  mould.     Flavor  with  lemon. 

Saked  Apples. — Core  and  pare  2  tart  apples;  fill  the  core-holes  with 
sugar;  grate  over  the  apples  a  little  nutmeg;  add  a  little  water  to  baking- 
pan  and  put  in  oven  and  bake  until  the  apples  are  soft.  Serve  with  rich 
milk -or  cream.     Sprinkle  with  icing  sugar,  if  not  sweet  enough. 

Cornstarch  Pudding. — Take  1  pint  of  milk,  and  mix  with  it  2  table- 
spoonfuls  of  cornstarch;  flavor  to  taste;  then  boil  the  whole  eight  minutes; 
allow  it  to  cool  in  a  mould. 

Custard  Pudding. — Break  1  es:g  into  a  teacup,  and  mix  thoroughly 
with  sugar  to  taste;  then  add  milk  to  nearly  fill  the  cup,  mix  again,  and 
tie  over  the  cup  a  small  piece  of  linen;  place  the  cup  in  a  shallow  saucepan 
half-full  of  water  and  boil  for  ten  minutes. 

If  it  is  desired  to  make  a  light  batter  pudding,  a  teaspoonful  of  flour 
•should  be  mixed  in  with  the  milk  before  tying  up  the  cup. 

Infant's  Gelatine  Food. — About  1  teaspoonful  of  gelatine  should  be 
dissolved  by  boiling  in  ^/o  pint  of  water.  Toward  the  end  of  the  boiling 
1  gill  of  cows^  milk  and  1  teaspoonful  of  arrowroot  (made  into  a  paste  with 
cold  water)  are  to  be  stirred  into  the  solution,  and  1  to  2  tablespoonfuls  of 
cream  added  just  at  the  termination  of  the  cooking.  It  is  then  to  be  mod- 
erately sweetened  with  white  sugar,  when  it  is  ready  for  use.  The  whole 
preparation  should  occupy  about  fifteen  minutes. 

Junket  of  Milk  and  Egg.— Beat  1  egg  to  a  froth  and  sweeten  with  2 
teaspoonfuls  of  white  sugar.  Add  this  to  ^/o  pint  of  warm  milk;  then 
add  1  teaspoonful  of  essence  of  pepsin  (Fairchikl)  ;  let  it  stand  till  it  is 
curdled.     The  above  is  useful  in  typhoid  and  similar  wasting  diseases. 

Junket. — Add  1  teaspoonful  of  liquid  rennin  to  1  pint  of  milk.  Mix 
and  heat  until  the  steam  rises.  Pour  into  cups  and  set  aside  to  cool. 
Flavor  with  vanilla  if  desired.  Or,  to  a  bowl  containing  8  ounces  of  cool 
milk,  add  1  teaspoonful  of  pepsencia  (Fairchikl).  Mix  thoroughly.  Place 
bowl  in  pan  of  boiling  hot  water,  two  minutes.  Remove,  and  let  stand  until 
jellied. 

Predigested  Eggs. — Break  a  fresh  egg.  After  thoroughly  stirring  add 
to  it  2  grains  of  caroid  powder  and  stir  thoroughly.  The  yolk  is  at  once 
changed  into  a  limpid  liquid  and  soon,  though  not  so  quicklv,  the  albumin 
is  completely  dissolved.     This  is  done  at  a  temperature  of  70°   to  80°   F. 

Predigested  Rice. — Take  V^  pound  of  rice,  add  water,  and  boil  until 
soft.     Break  grains  by  passing  through  a  colander.     Take,  of  bana-diatase. 


8^2  MISCELLANEOUS. 

8  grains/  and  dissolve  it  in  1  ounce  of  water  and  add  to  the  rice,  which  must 
be  kept  warm,  but  not  hot.  Let  stand  for  two  hours  at  a  temperature  of 
105°  F.  When  rice  is  thoroughly  softened,  season  with  salt,  sparingly. 
Add  a  little  cream  if  desired.     Serve  hot  or  cold. 

Rice  Pudding. — Boil  a  teacupful  of  rice,  drain  off  the  water;  add  a 
tablespoonful  of  cold  butter.  Mix  with  it  a  cupful  of  sugar,  a  quarter  tea- 
spoonful  of  ground  nutmeg,  and  a  quarter  teaspoonful  of  cinnamon.  Beat 
up  4  eggs  very  light,  whites  and  yolks  separately;  add  them  to  the  rice; 
stir  in  a  quart  of  sweet  milk  gradually.  Butter  a  pudding  dish,  turn  in 
the  mixture,  and  bake  one  hour  in  a  moderate  oven. 

If  you  have  cold  cooked  rice,  first  soak  it  in  the  milk,  and  proceed 
as  above. 

Sago  Pudding. — Same  as  above  recipe,  sago  being  substituted  for  rice. 

Soft  Custard. — Take  of  cornstarch  2  tablespoonfuls  to  1  quart  of  milk; 
mix  the  cornstarch  with  a  small  quantity  of  the  milk,  and  flavor;  beat  up 
2  eggs.  Heat  the  remainder  of  the  milk  to  near  boiling;  then  add  the 
mixed  cornstarch,  the  eggs,  4  tablespoonfuls  of  sugar,  a  little  butter,  and 
salt.     Boil  the  custard  two  minutes,  stirring  briskly. 

Tapioca  Cream. — Take  1  pint  of  milk,  2  tablespoonfuls  of  tapioca,  2 
tablespoonfuls  of  sugar,  1  saltspoonful  of  salt,  and  2  eggs.  Wash  the 
tapioca.  Add  enough  water  to  cover  it,  and  let  it  stand  in  a  warm  place 
until  the  tapioca  has  absorbed  the  water.  Then  add  the  milk  and  cook  in 
a  double  boiler,  stirring  often  until  the  tapioca  is  clear  and  transparent. 
Beat  the  yolks  of  the  eggs.  Add  the  sugar  and  salt  and  the  hot  milk. 
Cook  until  it  thickens.  Eemove  from  the  fire.  Add  the  whites  of  the  eggs, 
beaten  stiff.     When  cold,  add  1  teaspoonful  of  vanilla. 

Modified  Cov^^s'  Milk. 

Humanized  Milk. — A  pint  of  milk  is  set  aside  until  the  cream  rises, 
and  this  cream  is  skimmed  off  and  kept.  To  the  milk  remaining  is 
added  enough  rennet  to  curdle  it.  The  whey  is  strained  off  the  curd  and 
added,  with  the  previously  separated  cream,  to  a  pint  of  fresh  cows'  milk. 
This  is  known  as  humanized  milk.  In  some  infants  it  will  be  well  borne 
during  the  first  three  months,  and  to  this  can  be  added  farinaceous  liquid 
for  dilution  if  required. 

Pasteurized  Milk. — This  is  really  partially  sterilized  milk,  and  consists 
in  heating  to  a  temperature  of  140°  F,  instead  of  212°  F,,  this  heating  to 
be  continued  from  ten  to  twenty  minutes.  Pasteurized  milk  should  only  be 
used  during  the  twenty-four  hours  following  this  process.  A  good  apparatus 
for  this  purpose  is  Kilmer's  pasteurizing  apparatus. 


^American  Ferment  Company, 


DIETARY.  873 

Predigested  or  Peptonized  Milk. — ^This  is  milk  in  which  the  proteins 
are  changed  to  peptones,  or,  in  other  words,  digested,  by  the  addition  and 
action  of  pancreatic  ferment.  This  process  may  be  stopped  when  partially 
performed,  giving  a  product  of  which  the  taste  is  not  objectionable;  or  it 
may  be  carried  on  to  complete  peptonization,  when  the  product  has  a  very 
bitter,  disagreeable  taste. 

Method. — To  partially  peptonize  milk,  add  to  1  pint  of  fresh  cows' 
milk  and  4  ounces  of  water,  5  grains  of  pancreatic  extract  and  15  grains  of 
bicarbonate  of  soda.  Allow  this  to  stand  at  a  temperature  of  105°  to  115° 
P.  for  five  to  twenty  minutes,  then  bring  to  a  boil  to  kill  the  ferment,  or 
stand  on  ice  to  prevent  its  further  action.  If  the  milk  is  to  be  used  at  once, 
neither  of  these  latter  is  necessary. 

To  peptonize  the  milk  completely,  allow  the  process  to  continue  for 
one  to  two  hours.  After  this  time  the  addition  of  acid  produces  no  coagu- 
lation. 

In  infant-feeding  it  is  better  to  peptonize  a  modified  than  a  whole 
milk.  Peptonized  milk  is  frequently  very  useful  in  feeding  an  infant  with 
feeble  digestive  powers;  but  it  is  unwise  to  continue  its  use  over  too  long 
a  period,  as  then  the  infant's  stomach,  being  called  on  to  do  no  work,  be- 
comes enfeebled  from  disuse,  and  gradually  unable  to  perform  its  proper 
function. 

Whey. — By  coagulating  1  pint  of  fresh  (raw)  milk  by  adding  a  tea- 
spoonful  of  essence  of  pepsin,  and  allowing  this  to  stand,  solid  curd  is 
formed,  swimming  in  a  liquid  (whey) .  This Jias  the  following  composition : 
Proteins,  0.86  per  cent. ;  fat,  0.33  per  cent. ;  sugar,  4.79  per  cent. ;  salts, 
0.65  per  cent. ;  water,  93.3  per  cent. 

When  such  whey  is  added  to  milk  for  an  infant  under  6  weeks  take, 
of  whey,  2  parts;  milk,  1  part.  This  can  be  increased  until  equal  parts 
of  milk  and  whey  are  used  for  a  child  several  months  old. 

Preparation  of  Sweet  Whey. — Sweet  whey  is  best  made  by  the  follow- 
ing method :  For  each  pint  of  whey  needed  take  1  quart  of  raw  milk 
or  fat-free  milk,  heated  to  37.7°  C.  (100°  P.),  and  add  8  cubic  centimeters 
(3  drachms)  of  the  essence  of  pepsin  or  some  of  the  preparations  of  liquid 
rennet.  This  will  precipitate  the  casein  in  the  form  of  a  curd,  which  is 
then  broken  up  with  a  fork;  the  fluid  which  remains  is  the  whey.  This 
is  strained  through  two  thicknesses  of  boiled  cheese-cloth  and  one  thick- 
ness of  absorbent  cotton  and  slowly  cooled  to  a  temperature  of  10°  C.  (50° 
P.),  and  kept  on  ice  until  needed.  If  the  whey  is  to  be  mixed  with  cream, 
it  must  first  be  heated  to  65.5°  C.  (150°  P.),  in  order  to  kill  the  rennet 
enzyme.  Whey  mixtures  should  not  be  heated  above  68.3°  C.  (155°  P.) 
if  one  wishes  to  keep  safely  under  the  coagulation-point  of  the  lactalbumin. 
Add  1  teaspoonful  of  cane-sugar  to  each  pint  of  liquid. 


874  MISCELLANEOUS. 

Miscellaneous. 

Milk  Toast. — Take  1  cupful  of  milk,  y^  teaspoonful  of  cornstarch,  y^ 
teaspoonful  of  butter,  2  slices  of  dry  toast,  1  saltspoonful  of  salt.  Scald 
the  milk.  Add  the  moistened  cornstarch.  Melt  the  butter  in  a  saucepan; 
when  hot  and  bubbling,  pour  in  the  hot  milk  slowly,  beating  all  the  time 
until  smooth.  Let  it  boil  up  once.  Then  add  the  salt.  Toast  2  slices  of 
bread.  Pour  the  thickened  milk  over  the  slices.  Let  it  stand  a  few 
minutes.     Serve. 

Scraped  Beef. — Scraped  beef  is  prepared  by  scraping  with  a  dull  knife 
some  raw  or  underdone  lean  beef.    Add  salt  and  serve  on  bread  or  biscuit. 

Scrambled  Eggs. — Take  2  eggs,  a  pinch  of  salt,  2  tablespoonfuls  of 
milk,  and  a  small  piece  of  butter.  Beat  the  eggs  lightly,  add  the  salt  and 
milk.  Put  the  butter  into  a  saucepan;  when  melted  and  hot,  add  the  eggs. 
Stir  until  of  a  soft,  creamy  consistency.    Serve  on  buttered  toast. 

Soft-boiled  Eggs. — Drop  2  eggs  into  enough  boiling  water  to  cover 
them.  Let  them  stand  on  the  back  of  stove,  where  the  water  will  keep  hot, 
but  not  boil,  for  eight  minutes.  An  ^gg  to  be  properly  cooked  should  never 
be  boiled  in  boiling  water,  as  the  white  hardens  unevenly  before  the  yolk  is 
cooked.    The  yolk  and  white  should  be  of  jelly-like  consistency. 


CliAPTEll  11. 
THE  EXAMINATION  OF  THE  GASTRIC  CONTENTS  IN  CHILDREN.^ 

Chemical  Examination. - 

Afteu  tlie  removed  chyle  is  filtered  it  is  ready  for  the  following 
tests  :— 

Hydrochloric  Acid. — Free  hydrochloric  acid  turns  Congo-red  a  deep 
blue  color;  but  as  the  presence  of  large  quantities  of  lactic  and  other  or- 
ganic acids  gives  the  same  reaction,  and  as  the  phloroglucin-vanillin  (Giinz- 
burg's  reagent)  does  not  respond  to  the  organic  acids,  it  is  better  not  to 
depend  upon  the  simpler  Congo-red  test.  One  or  two  drops  of  the  filtered 
stomach-contents  are  placed  on  a  white  porcelain  dish;  the  same  amount 
of  the  reagent  is  added  and  thoroughly  mixed  with  a  glass  rod ;  the  dish 
is  then  gently  warmed  over  the  flame.  The  appearance  of  a  bright  cherry- 
red  color  on  the  edge  of  the  residue  indicates  the  presence  of  free  hydro- 
chloric ficid. 

To  IQ  cubic  centimeters  of  the  filtered  chyle  add  1  drop  of 
phenolphthalein  solution;  to  this  add  drop  by  drop  from  the  burette  a 
decinormal  solution  of  potassium  or  sodium  hydrate  until  after  thoroughly 
stirring,  a  pink  color  persists;  now  read  carefully  the  number  of  cubic 
centimeters  of  the  alkali  solution  used,  multiply  by  10  and  0.00365  (the 
decinormal  factor  of  HCl)  and  the  result  is  the  percentage  of  HCl.  If  suf- 
ficient material  is  at  hand,  the  estimation  should  be  repeated  to  avoid  pos- 
sible error. 

Lactic  Acid  (IJffelmann's  Test). — One  drop  of  the  solution  of  ferric 
chloride  is  added  to  30  cubic  centimeters  of  the  V2  P^r  cent,  carbolic  acid 
solution;  this  is  diluted  till  a  transparent  amethyst  blue  color  is  obtained. 
A  few  drops  of  the  fluid  to  be  tested  added  to  a  few  cubic  centimeters  of 
this  solution  in  a  test-tube,  change  the  amethyst-blue  to  a  canary-yellow  if 
lactic  acid  be  present.  On  account  of  the  presence  of  various  other  substances 
this  test  is  sometimes  not  distinctive  when  the  untreated  chyle  is  used.  A 
more  certain  procedure  is  to  add  to  10  cubic  centimeters  of  the  filtered 
chyle  in  a  test-tube  110  cubic  centimeters  of  ether;    shake  thoroughly; 


'  V/ith  a  soft  flexible  catheter  I  syphon  the  gastric  contents  about  two  hours 
after  feeding;  if  the  stomach  is  irritable  and  children  vomit,  then  the  vomited 
material  is  used. 

^  I  am  indebted  to  Boas'  valuable  book  on  "Diseases  of  the  Stomach"  for  many 
points  in  the  chemical  examination  and  methods  used. 

(875) 


376  MISCELLANEOUS. 

allow  the  ether  to  separate ;  decant  the  ether  into  a  clean  test-tube ;  place 
the  test-tube  containing  the  ether  in  a  glass  of  warm  water  till  the  ether 
has  evaporated;  add  5  to  10  cubic  centimeters  of  distilled  water  to  the 
residue,  and  test  as  above  for  lactic  acid. 

Propeptone. — To  5  cubic  centimeters  of  chyle,  add  5  cubic  centimeters 
of  saturated  solution  of  sodium  chloride  and  2  drops  of  acetic  acid.  A 
cloudiness  or  precipitate  indicates  propeptone,  especially  if  the  precipitate 
disappears  on  heating  and  returns  on  cooling. 

Peptone. — Filter  out  any  propeptone  from  the  last  named;  add  an 
excess  of  sodium  hydrate  solution ;  mix  thoroughly  and  add  1  or  2  drops  of 
a  weak  solution  of  copper  sulphate  {^/^  per  cent.);  the  appearance  of  a 
violet-red  or  old-rose  color  indicates  peptone.  This  is  the  so-called  biuret 
reaction  which  most  peptones  and  albumoses  give. 

Pepsin. — For  this  test  we  require  uniform,  small  pieces  of  coagulated 
albumin;  these  should  be  little  circular  slices  of  hard  boiled  white  of  egg, 
1  centimeter  in  diameter  and  1  millimeter  in  thickness,  which  may  be 
preserved  in  glycerine.  One  of  these  discs  is  placed  in  a  test-tube 
containing  5  cubic  centimeters  of  filtered  chyle  and  kept  at  a  temperature 
of  99°  F. ;  if  it  has  been  already  shown  that  hydrochloric  acid  is  absent, 
1  drop  or  2  of  dilute  hydrochloric  must  be  added.  The  tube  is  observed 
every  twenty  to  thirty  minutes  to  note  the  progress  of  digestion  and  the 
time  required  for  complete  disappearance  of  the  egg  albumin. 

Rennet. — Add  a  few  drops  of  chyle  to  5  or  10  cubic  centimeters  of 
milk  and  place  tube  in  water  at  a  temperature  of  99°  F. 

Motility. — The  motility  of  the  stomach  may  be  tested  in  various  ways; 
probably  the  salol-test,  although  open  to  many  objections,  is  the  most  used. 

This  test  finds  the  foundation  for  its  use  in  the  fact  that  salol  is  not 
absorbed  until  it  reaches  the  alkaline  secretions  of  the  intestine,  by  which 
it  is  decomposed.  The  test  is  untrustworthy  when  the  stomach  secretion 
is  alkaline.  The  time  between  ingestion  and  the  appearance  of  salicyluric 
acid  in  the  urine  is  noted  by  examining  the  urine  at  intervals  of  one-half 
and  one  hour  after  taking  15  grains  of  salol  (immediately  after  meal). 
If  salicyluric  acid  be  present  in  the  urine,  the  addition  of  a  few  drops  of 
a  solution  of  ferric  chloride  gives  a  violet  color.  If  the  appearance  of  the 
test  be  delayed  longer  than  an  hour  or  an  hour  and  fifteen  minutes,  the 
motility  is  usually  considered  below  normal. 


CHAPTER  III. 

URINE. 

Method  of  Collecting  Urine. 

In  collecting  urine  from  an  infant  we  can  apply  a  pad  of  sterile  ab- 
sorbent cotton  or  a  flat  sterile  sponge  to  the  vulva.  After  urination  the 
urine  absorbed  can  be  filtered  into  a  bottle.  If  the  urine  thus  secured  is 
rot  sufficient  for  examination,  the  method  can  be  repeated  several  times. 
In  boys  the  smallest  size  rubber  ice-bag  can  be  drawn  over  the  genitals  and 
a  specimen  secured  in  this  manner. 

If  for  any  reason  this  method  cannot  be  carried  out,  and  it  is  vital 
that  the  examination  be  made,  then  an  infant's  size  catheter  may  be  used 
to  draw  off  the  urine. 

The  First  Urine. 

The  first  urine  drawn  by  catheter  is  acid,  almost  always  clear  and  but 
slightly  colored.  During  the  first  four  or  five  days  it  is  more  or  less  cloudy 
from  the  presence  of  epithelial  cells  from  the  urinary  passage,  and  uric 
acid  salts.  The  specific  gravity  averages  about  1012.  The  sediment  always 
contains  normal  epithelial  cells,  various  forms  of  uric  acid  crystals,  and 
now  and  then  hyaline  casts.  The  amount  of  urine  is  small  (Morse).  This 
is  due  in  part  only  to  the  insufficient  supply  of  milk,  as  the  amount  is  also 
small  in  bottle-fed  infants.  It  increases  rather  rapidly  about  the  fourth 
day,  20  to  50  cubic  centimeters  being  passed  in  the  first  three  days,  and 
about  100  cubic  centimeters  on  the  fourth  day.  In  the  second  week  it 
averages  between  200  and  300  cubic  centimeters. 

The  proportion  of  water  eliminated  in  the  urine  to  that  taken  in  the 
food  is  greater  after  the  fourth  day,  averaging  22  per  cent,  to  25  per  cent, 
before,  and  50  per  cent,  to  60  per  cent,  after. 

The  urine  of  hreast-fed  hahies  almost  never  contains  indican,  that  of 
the  artificially  fed  baby  usually  but  slight  traces.  Urobilin  is  never  pres- 
ent in  that  of  the  breast-fed,  seldom  in  that  of  the  artificially  fed.  It  does 
not  contain  albumin,  and  sugar  is  absent  with  the  ordinary  reagents.  The 
sediment  is  slight,  and  consists  entirely  of  cells.  One-third  to  one-half 
gram  of  urea  per  kilo  of  body  weight  is  said  to  be  passed  in  twenty-four 
hours.  Figures  are  of  but  little  use,  however,  as  the  amount  of  urea  varies 
with  the  character  of  the  food.  It  is  pretty  certain,  nevertheless,  that 
from  40  to  50  per  cent,  of  the  nitrogen  ingested  appears  in  the  urine. 
The  amount  of  urine  is  relatively  large.     It  varies  between  200  and  500 

(877) 


878  MISCELLANEOUS. 

cubic  centimeters  from  one  to  six  months,  and  between  250  and  600  cubic 
centimeters  up  to   3  years. 

The  urine  (d  the  new-born  is  rich  in  sodium  chloride,  which  salt 
diminishes  with  age.  During  the  first  and  second  months  of  life  it  is  in 
the  same  proportion  as  in  adults.  From  the  third  to  the  fifth  year,  com- 
puted by  kilogram  weight,  the  amount  is  0.57  gram;  at  11  years,  0.44 
gram,  and  at  16  years,  0.18  gram. 

Phosphoric  acid  is  seldom  found,  but  when  met  with  it  is  always  in 
very  minute  quantity. 

Uric  acid  is  present  in  the  earliest  urine,  and  the  quantity  regularly 
increases  up  to  the  third  day,  when  it  rapidly  diminishes. 

On  examining  the  kidneys  of  a  new-born,  the  papillae  will  be  found 
filled  with  a  reddish  substance  which  obstructs  the  urinary  ducts;  this, 
as  is  well  known,  is  nothing  more  than  uric  acid  infarction  and  has  no 
pathological  significance. 

Parrot  and  Eobin  found  urate  of  soda,  sulphate  of  calcium,  mag- 
nesium, potassium,  benzoic  acid,  allantoidin,  and  mucin,  and  Cruse  denies 
the  presence  of  sugar,  oxalate  of  calcium,  or  hippuric  acid.  Creatinine 
and  indican  are  not  found  in  the  urine  of  the  new-bom  or  wet-nursed. 
Xanthine  is  relatively  abundant  in  cases  of  nephritis. 

In  infantile  atrophy,  as  may  be  presumed,  the  quantity  of  urine  is 
far  below  the  normal;  it  is  yellow,  acid  reaction,  often  contains  organic 
deposits,  sugar,  albumin  and  an  excess  of  urea  and  phosphates. 

In  icterus  neonatorum  the  urine  is  pale-yellow,  and  contains  urates, 
epithelial  cells,  and  yellow  masses  of  pigment. 

The  urine  of  infants  with  scleroderma  is  reddish,  acid  with  uratic 
deposits,  and  slight  excess  of  urea. 

Albumin. 

The  i^resence  of  albumin  is  always  of  importance,  although  not  always 
due  to  an  inflammatory  process  of  the  kidneys.  It  is  often  the  sign  of  a 
simple  congestion  in  athrepsia,  cholera  infantum,  general  or  intestinal 
tuberculosis,  intestinal  catarrh,  typhoid  and  scarlet  fever. 

"A  small  amount  of  albumin  in  the  form  of  nucleo-albumin  is  almost 
constantly  present  in  the  urine  during  the  first  four  days  of  life.  It  often 
persists  for  two  weeks,  and  not  infrequently  for  two  months.  There  is 
much  ditference  of  opinion  as  to  the  cause  of  this  albuminuria.  It  has 
been  attributed  to  the  changes  in  the  circulation  at  birth,  to  hyperaemia 
resulting  from  the  changes  in  the  metabolism  after  birth,  to  renal  disease 
in  the  mother,  and  to  irritation  from  uric  acid.  It  is  doubtful  if  any  of 
these  explanations  are  correct.  The  latest  investigations  show  that  albu- 
minuria is  no  more  common  in  the  children  of  women  suffering  from 
nephritis  or  eclampsia  than  in  others.    If  uric  acid  is  the  cause,  its  action 


URINE,  879 

is  probably  as  a  chemic  rather  than  as  a  mechanic  irritant.  Many  observ- 
ers regard  this  albuminuria  as  physiologic.  It  is  hardly  safe  to  consider 
it  so,  however,  until  more  is  known  about  metabolism,  the  changes  due  to 
nourishment,  and  disturbances  of  nutrition  in  the  new-born.  Whatever 
the  cause,  it  is  certainly  not  a  serious  condition,  and  ought  not  to  be  looked 
upon  as  the  forerunner  of  chronic  nephritis  in  later  life." 

In  older  children  the  presence  of  albumin  in  the  urine  is  always 
pathological,  except  when  it  is  the  physiological  result  of  the  administra- 
tion of  certain  drugs  (tincture  of  iodine,  etc.). 

A  slight  amount  of  albumin  may  be  found  in  nephritic  colic  due  to 
the  stimulus  which  the  uric  acid  exerts  upon  the  renal  parenchyma.  At 
other  times,  when  present,  there  is  an  actual  inflammation  of  the  kidneys, 
as  in  scarlatina  and  diphtheria;  there  may  be  an  amyloid  degeneration 
without  its  being  possible  to  discover  any  albumin  in  the  urine. 

Sometimes  children  will  be  found  pale,  the  urine  perhaps  abundant 
or  diminished  in  quantity;  it  will  contain  albumin,  a  few  hyaline  casts, 
uric  acid  and  epithelium,  yet  they  will  have  good  appetite,  will  play  and 
appear  otherwise  quite  well.  Others  become  languid,  lose  their  appetite, 
complain  of  headaches,  painful  micturition,  and  will  pass  a  turbid  and 
sedimentous  urine.     In  these  cases  albumin  soon  appears. 

The  more  severe  cases  suffer  from  anuria;  partial  cedema  will  occur 
in  the  eyelids,  on  the  dorsum  of  the  foot,  etc.  The  next  day  the  amount 
of  urine  will  have  been  50  to  100  grams  in  twenty-four  hours.  This  will 
increase,  perhaps,  never  to  return  to  the  normal. 

The  color  of  the  urine  in  Bright's  disease  will  be  variable,  according 
to  the  amount  of  blood  which  it  may  contain,  of  acid  reaction,  and  average 
specific  gravity  of  1010  to  1015.  Under  the  microscope  we  find  red  and 
white  corpuscles,  haematin,  renal  epithelium,  hyaline  or  granular  casts, 
uric  acid  crystals,  fat  globules,  and  detritus. 

Chronic  nephritis  may  be  the  result  of  an  acute  affection  complicating 
scarlet  fever.  In  these  cases  children  suffer  but  little  and  seldom  show 
more  than  a  few  oedematous  spots. 

These  forms  of  kidney  involvement  are  rather  rare,  and  eases  which 
have  been  diagnosed  as  such  have,  on  autopsy,  proven  to  have  been  cases 
of  amyloid  degeneration  due  to  syphilis,  malaria,  rachitis,  struma,  or 
tuberculosis. 

In  the  mild  forms  of  diphtheria  the  urine  suffers  no  change  what- 
ever, but  in  the  general  infection,  even  in  the  early  stages,  albuminuria  is 
found,  which  is  a  fairly  positive  evidence  of  systemic  infection.  If 
the  urine  diminishes  in  quantity  and  blood  corpuscles  are  found  under 
the  microscope  we  may  feel  sure  that  the  diphtheritic  process  has  invaded 
the  kidney,  or  else  that  a  nephritis  complicates  the  diphtheria. 

"In  rachitis,  albuminuria  is  comparatively  rare;  the  quantity  does  not 


880 


MISCELLANEOUS. 


change  materially,  but  the  calcium  salts  have  been  found  in  marked  dimin- 
ution. Marchand  and  Lehman  have  discovered  lactic  acid  present.  The 
phosphates  and  chlorides  are  in  very  small  quantities.  The  urine  of  leu- 
kaemic  patients  at  times  contains  albumin  and  many  lymph  corpuscles  as 
well  as  hyaline  casts.  The  uric  acid  and  hypoxanthine  are  in  greater 
quantity. 

^'Diabetes  mellitus  has  been  met  with  at  a  very  tender  age. 
"In  a  case  of  pseudo-hypertrophic  paralysis  Dennen  reports  marked 
glycosuria. 

"Hsemoglobinuria  is  found  in  Winckel's  disease,  and  the  same  as  in 
adults,  in  malaria,  syphilis,  and  as  a  result  of  exposure  to  cold. 

"Haematuria  and  pyuria  have  no 
special  significance  beyond  that  which 
they  have  in  adults. 

"Uric  acid  is  in  excess  during  the  first 
week  and  is  a  physiological  phenomenon; 
later  on,  deposits  of  urates  and  uric  acid 
appear  in  the  course  of  serious  diseases  of 
the  digestive  apparatus.  Under  other 
circumstances,  the  oxidation  of  nitrogen- 
ous substances  being  diminished  (by  dis- 
eases of  the  respiratory  or  central  nervous 
system),  deposits  of  oxalate  of  calcium 
occur. 

"Infarcts  of  uric  acid  may  be  found 
even  up  to  the  seventh  or  eighth  week. 
Children  will  strain,  make  repeated  ef- 
forts and  cry  out  during  urination;  the 
diapers    will    be    found    stained    with    a 
darker  urine  than  usual;  the  edges  of  the 
wet  surface  Mail  be  seen  reddened  by  a 
yellowish-pink  sandy  deposit.     A  careful 
analysis  of  this  urine  regularly  shows  an 
excess  of  uric  acid,  many  epithelial  cells, 
a  few  pus  corpuscles,  and  mucus  and  traces  of  albumin.     Quite  frequently 
the  urine  is  so  acid  as  to  produce  such  pronounced  evidences  of  pain  on  the 
part  of  the  infant  as  are  met  with  in  the  nephritic  colic  of  adults. 

"When  tubercle  bacilli  are  present  in  urinary  sediment,  the  diagnosis  of 
tuberculosis  of  the  kidneys,  ureters,  or  bladder  may  be  positively  made. 
Care  should  be  exercised  not  to  confound  the  tubercle  bacillus  with  the 
smegma  bacillus,  which  may  often  be  present  in  the  same  specimen  of 
urine  and  which  stains  like  the  former,  though  it  decolorizes  differently. 
*  It  can  be  procured  at  Eimer  &  Amend,  chemists'  supplies,  New  York  City. 


Fig.  •298. — Urino-Pyknometer,^ 
for  estimating  the  specific  gravity 
of  small  volumes  of  urine. 


URINE. 


881 


"The  epithelium  found  in  urinary  sediments  is  often  of  great  import- 
ance in  determining  in  what  part  of  the  genito-urinary  tract  tlie  lesion 
exists,  and  a  knowledge  of  the  histology  of  these  organs  will  sometimes 
prove  invaluable. 

"The  presence  of  echinococcus,  filaria,  etc.,  determines  the  exact  nature 
in  those  diseases. 

"Dysuria  is  not  always  a  manifestation  of  renal  or  vesical  disease,  since 
a  high  fever  may  at  times  originate  it.  In  such  cases  children  complain  or 
cry  out  on  attempting  to  urinate. 

"This  symptom  belongs  as  well  to  affections  of  the  external  genitals 
such  as  phimosis,  urethritis,  congenital  anomalies  of  the  urethra,  those  of 
the  labia  minora  in  females,  etc." 

Specific  Gravity. — The  specific  gravity  of  the  urine  is  best  taken  with 
a  hydrometer.  If  the  urine  is  very  scanty  an  instrument  called  the  urino- 
pyknometer,  devised  by  Dr.  Saxe,  should  be  used.  It  has  the  advantage  of 
giving  the  specific  gravity  when  only  1  drachm  or  3  cubic  centimeters  can 
be  procured. 

Test  foe  Albumin. 

Place  in  a  test-tube  about  half  a  teaspoonful  of  pure  water,  in  which 
dissolve  one  of  the  potassio-mercuric  iodide  tablets  and  one  of  the  citric 
acid  tablets.  To  this  solution  gradually  add,  drop  by  drop,  the  urine.  If 
a  gelatinous  precipitate  occurs,  it  may  consist  of  albumin,  an  alkaloid 
such  as  quinine,  or  peptone.  To  determine  which  of  these  three  sub- 
stances was  originally  present  in  the  urine,  heat  the  contents  of  the  tube 
to  the  boiling  point  and  note  if  the  precipitate  is  redissolved.  If  such  be 
the  case,  the  precipitation  was  due  to  peptone  and  not  albumin,  as  the 
latter  would  be  coagulated  and  would  not  be  dissolved.  If  the  precipitate 
consists  of  a  compound  of  the  reagent  with  an  alkaloid,  it  will  be  dis- 
solved completely  upon  the  addition  of  alcohol,  a  result  which  would  not 
occur  if  the  precipitate  consisted  of  albumin.  The  potassio-mercuric  iodide 
test  is  exceedingly  sensitive,  and  whenever  the  results  are  negative,  no 
precipitate  occurring  upon  the  addition  of  the  urine,  it  is  positive  evidence 
of  the  absence  not  only  of  albumin,  but  of  peptone  and  alkaloids  as  well. 
It  is  only  in  such  cases  where  a  precipitate  occurs  that  it  becomes  necessary 
to  apply  alcohol  and  heat  tests  to  determine  the  character  of  the  precipi- 
tate. 

Directions  for  Use. — In  testing  urine  for  albumin  with  nitric  acid,  fill 
the  large  tube  of  the  horismascope  two-thirds  full  of  the  urine,  which  must 
be  made  perfectly  clear  and  transparent,  if  necessary  by  filtration.  Then 
pour  into  the  funnel  tube  25  or  30  minims  of  nitric  acid,  which  will  pass 
down  through  the  capillary  tube  and  form  a  layer  underlying  the  urine. 

66 


882 


MISCELLANEOUS. 


If  albumin  is  present,  a  distinct  white  zone  will  presently  appear  at  the 
point  of  contact,  sharply  defined  against  the  black  background,  the  amount 
of  albumin  being  indicated  by  the  density  of  the  opaque  ring.  Sometimes 
air  will  remain  in  the  capillary  tube  of  the  instrument,  preventing  the  acid 
from  running  down  the  tube.  It  is  always  best  to  see  that  the  tube  is  free 
from  air  before  pouring  in  the  acid.  If  air  is  present,  it  can  generally  be 
driven  out  by  merely  tilting  the  instrument  or  it  may  be  driven  down  the 
tube  by  placing  the  thumb  or  middle  finger  on  top  of  the  funnel  so  as  to 
cover  it  completely  and  pressing  quickly  and  forcibly  so  as  to  cause  a  few 
bubbles  of  air  to  pass  through  the  urine. 

In  the  use  of  the  horismascope  in 
applying  the  nitric-acid  test  for  albu- 
min, these  advantages  are  secured: 

1.  The  acid  when  it  comes  in  con- 
tact with  the  urine  is  of  full  strength, 
rendering  the  test  much  more  delicate 
than  as  ordinarily  applied. 

2.  The  reaction  is  not  liable  to  be 
obscured  by  separation  of  uric  acid  or 
acid  urates,  such  separation  not  taking 
place  in  the  horismascope  until  after 
a  considerable  interval. 

3.  The  black  and  white  back- 
grounds of  the  instrument  render  much 
more  distinct  the  effects  produced  by 
the  reagent. 

4.  No  especial  skill  is  required  on 
the  part  of  the  operator. 

The  faintest  visible  trace  of  al- 
bumin as  shown  by  the  nitric  acid 
test  may  be  stated  to  be  ^/go  per  cent. 
One-fourth  of  1  per  cent,  is  just  suffi- 
cient to  make  the  albumin  layer  opaque  when  viewed  from  above.  If  larger 
amounts  are  present  the  percentage  may  be  approximately  estimated  by 
diluting  the  urine  until  the  opacity  is  reduced  to  that  corresponding  with 
0.25  per  cent. 

There  are  many  other  tests  which  can  be  advantageously  made  by 
introducing  the  reagent  from  beneath,  allowing  it  thus  to  form  a  distinct 
stratum  underlying  the  fluid  to  be  tested. 

In  testing  a  specimen  of  urine  it  is  always  best  to  first  determine  its 
reaction.  For  this  purpose  red  and  blue  litmus  paper  should  always  be  at 
hand.  A  small  piece  of  each  kind  of  paper  should  be  added  to  the  specimen 
and  the  result  be  observed.     If  the  urine  is  alkaline  the  red  litmus  paper 


Fig.  299.— The  Horismascope  or  Albumo- 
scope.  A  uew  instrument  for  determining  the 
presence  and  amount  of  albumin  in  theurine. 
No  liability  of  the  acid  mixing  with  theurine. 
The  slightest  visible  trace  of  albumin  can  be  in- 
stantly detected  against  the  dark  background. 
Color  reactions  due  to  urinary  and  biliary  pig- 
ments are  clearly  shown  against  the  white 
backgrjund. 


URINE. 


883 


will  turn  blue,  and  if  it  is  acid  the  blue  litmus  paper  will  turn  red.  It  is 
very  important  that  when  testing  lor  sugar  the  urine  should  be  slightly 
alkaline,  and  when  testing  for  albumin  it  should  be  slightly  aci'l.  In  order 
to  render  the  specimen  slightly  alkaline  or  slightly  acid  according  to  the 
test  that  is  to  be  applied,  sodium  carbonate  tablets  and  citric  acid  UiMets 
should  bo  used. 

Robert's  Albumin  Test. 

IJ  Sat.  sol.  magnes.  sulph.  (c.  p.) 5  ounces 

Nitric  acid  (c.  p.) 1  ounce 

This  test  is  a  cold  one,  viz. :  put  about  1  cubic  centimeter  of  solution 
into  medium-sized  test-tube — incline  on  a  steady  rest  on  an  angle  of  45 
degrees.  With  a  slender  pipette  allow  the  filtered  urine  to  be  tested — to 
flow  very  slowly  down  the  side  of  the  tube.  It  will  float  above  test  solution. 
Use  about  1  cubic  centimeter  of  urine.  Examine  in  front  of  the  window 
by  daylight,  with  aid  of  black  background.  A  sharp  clear-cut,  white  line 
will  appear  at  contact  line  if  albumin  is  present.  A  wide  band  of  white 
is  not  always  indicative  of  albumin,  neither  is  a  narrow  zone  above  in  the 
urine,  which  may  be  due  to  mucus.    The  sharp,  clear-cut  zone  is  distinctive. 

A  New  Test  for  Albumin.^ — This  new  and  simple  test  is  based  upon  the 
following  facts : — 

1.  Albumin  is  coagulated  by  carbolic  acid. 

2.  Equal  volumes  of  non-albuminous  urme  and  a  mixture,  composed 
of  equal  parts  of  carbolic  acid  and  glycerine,  form  an  emulsion  which  clears 
up  entirely  upon  agitation,  leaving  a  perfectly  transparent  and  highly  re- 
fractive liquid. 

3-.  Equal  volumes  of  albuminous  urine  and  the  above  mentioned  carbol- 
glycerine  solution,  when  mixed  together,  produce  a  white  turbidity,  which 
remains,  in  spite  of  agitation,  and  does  not  precipitate  on  standing  nor 
redissolve. 

The  test  is  very  sensitive,  distinctly  showing  the  presence  of  0.1  per 
cent,  of  albumin  in  the  urine,  the  degree  of  turbidity  being  proportionate 
to  the  percentage  of  albumin  contained  in  the  urine. 

Test. — Two  cubic  centimeters  of  carbol-glycerine  solution  are  poured 
into  a  small  test-tube,  and  2  cubic  centimeters  of  the  filtered  urine  are 
added.  Mix  thoroughly  with  a  glass  rod,  or  agitate.  If  a  clear,  transparent 
liquid  results,  there  is  no  albumin  present;  but  if  the  slightest  turbidity  is 
noticeable  the  urine  is  albuminous. 

The  Diazo  Reaction  in  Urine. — The  diazo  test  Mas  suggested  by 
Ehrlich,  in  1882,  as  a  valuable  diagnostic  measure  in  tj^Dhoid  fever,  al- 
though he  admitted  the  occurrence  of  this  reaction  in  a  few  other  con- 
ditions shortly  to  be  considered. 


^Fuhs,  Medical  Record,  March  8,  1902. 


884  MISCELLANEOUS. 

The  diazo  reaction  depends  upon  the  fact  that  if  sulphanilic  acid 
(amidosulphobenzol)  be  acted  upon  by  HNO,  diazosulphobenzol  is  formed, 
which  unites  with  certain  aromatic  substances  occasionally  present  in  the 
urine  to  form  aniline  colors. 

Eriedenwald  has  recently  reviewed  the  literature  of  this  reaction,  and 
showed  that  many  of  the  contradictory  results  obtained  by  some  observers 
are  due  to  failure  in  carrying  out  Ehrlich's  methods  in  performing  the 
test,  which  is  best  accomplished  as  follows: — 

To  obtain  diazosulphobenzol  in  a  perfectly  fresh  condition  sulphanilic 
acid  is  kept  in  solution  with  hydrochloric  acid;  to  this  sodium  nitrate  is 
added,  whereupon  HISTO  is  liberated  and  diazosulphobenzol  is  formed. 

Process. — Two  solutions  are  prepared,  as  follows: — 

1.  Two  grams  of  sulphanilic  acid,  50  cubic  centimeters  of  hydrochloric 
avid,  1000  cubic  centimeters  of  distilled  water. 

2.  A  0.5  per  cent,  solution  of  sodium  nitrite. 

In  performing  the  test,  50  parts  of  No.  1  and  1  part  of  No.  2  are 
mixed,  and  equal  parts  of  this  mixture  and  of)  the  urine  in  a  test-tube  are 
rendered  strongly  alkaline  with  ammonia.  If  the  reaction  be  positive  the 
solution  assumes  a  carmine-red  color,  which  on  shaking  must  also  appear 
on  the  foam.  Upon  standing  for  twenty-four  hours  a  greenish  precipitate 
is  formed. 

The  test  must  not  be  considered  positive  unless  a  distinct  red  colora- 
tion extends  to  and  includes  the  foam  on  shaking. 

Indican. 

To  two  inches  of  urine  in  a  test-tube  add  ten  drops  of  strong  hydro- 
chloric acid  and  two  drops  of  fuming  nitric  acid,  allow  to  cool ;  add  one-half 
inch  of  chloroform  and  shake  up  thoroughly.  If  indican  is  present,  the 
chloroform,  when  it  again  sinks  to  the  bottom  of  the  test-tube,  will  be 
tinged  either  blue  or  red. 

Fallacy. — ^Albumin  interferes  with  the  test — if  present  remove  same 
by  adding  acetic  acid,  boiling,  and  filtering  off  the  coagulated  protein. 

Jaffe's  test  consists  in  mixing  10  cubic  centimeters  of  strong  hydro- 
chloric acid  with  an  equal, volume  of  urine  in  a  test-tube,  and,  while  shak- 
ing, add  drop  by  drop  a  perfectly  fresh,  saturated  solution  of  chloride  of 
lime,  or  chlorine  water,  until  the  deepest  obtainable  blue  color  is  reached. 
The  mixture  may  next  be  titrated  with  chloroform,  which  readily  takes  up 
the  indican  and  holds  it  in  solution,  and  the  quantity  present  may  be 
approximately  estimated  according  to  the  depth  of  the  color.  If  the  urine 
contains  albumin  it  should  be  removed  before  applying  this  test,  otherwise 
the  clue  color,  often  arising  from  the  mixture  of  hydrochloric  acid  and 
albumin  after  standing,  may  prove  misleading. 


TEST  FOR  SUGAR  IN  URINE.  885 


Test  for  Sugar  (Glucose)  in  Ukixk. 

The  best  test  for  sugar  is  furnished  by  the  indigo  and  <?odium.  car- 
bonate tablets.  This  test  is  applied  by  first  placing  in  a  test-tube  about 
half  a  teaspoonful  of  water,  one  of  the  indigo  and  sodium  carbonate  tab- 
lets, and  one  of  the  sodium  carbonate  tablets.  Heat  the  contents  of  the 
tnbe  gently  until  solution  is  effected,  and  then  add  Idrop  of  the  urine  to 
be  tested,  keeping  the  fluid  at  the  boiling  point  without  allowing  it  to  hoil. 
If  no  effect  is  produced  add  a  second  drop  of  the  urine  and  heat  as  before. 
If  no  change  of  color  results  add  another  drop  of  the  specimen,  and  so  on 
until  at  Itast  five  drops  have  been  added.  If  any  notable  amount  of  sugar 
is  present,  one  or  at  least  two  drops  will  suffice  to  bring  about  the  reaction. 
The  fluid  will  change  from  pure  blue  to  amethyst,  then  to  purple  and  red, 
finally  fading  to  a  pale  yellow.  If  the  quantity  of  sugar  is  very  small,  the 
■color  will  change  only  to  a  purple  or  red,  and  in  nearly  every  case  five  drops 
of  normal  urine  will  produce  this  change. 

If  one  drop  of  the  urine  produces  a  strong  reaction,  dilute  the  urine 
to  one-half,  one-quarter,  one-eighth,  etc.,  in  succession  until  a  single  drop 
ceases  to  produce  a  visible  change,  and  estimate  roughly  in  this  manner 
the  quantity  of  sugar  present.  While  observing  the  various  changes  of 
color  which  the  liquid  undergoes,  if  sugar  is  present,  any  agitation  of  the 
solution  should  be  carefully  avoided.  The  reason  for  this  precaution  is 
readily  explained  by  the  fact  that  the  original  blue  color  of  the  solution 
may  be  restored  by  simply  shaking  the  liquid.  This  remarkable  effect  is 
not  due  to  cooling,  but  to  the  oxidizing  influence  of  the  air. 

In  regard  to  the  comparative  value  of  tests  for  sugar,  it  may  be  said 
that  the  copper  test  is  the  least  trust^^orthy.  x^mong  the  normal  constit- 
uents of  the  urine,  uric  acid  is  capable  of  reducing  copper  compounds,  and 
numerous  substances  which  may  accidentally  be  present  have  a  similar 
action.  The  indigo  test  is  capable  of  detecting  a  smaller  quantity  of  sugar 
in  the  urine  than  any  otlier  reagent.  One  drop  of  a  solution  of  glucose, 
containing  a  half  grain  to  the  fluidounce,  shows  a  distinct  reaction. 

Nylander's  Test. — Solution  is  composed  of  3.0  bismuth  subnitrate,  4.0 
Eochelle  salt,  and  100.0  of  an  8  per  cent,  solution  of  sodium  hydrate.  One 
part  of  this  solution  added  to  9  parts  by  volume  of  the  urine  and  the  mix- 
ture boiled  for  a  time.  The  reaction  begins  as  a  grayish  black  coloration 
of  the  whole  mixture,  which  soon  becomes  a  deep  black. 

This  test  is  a  delicate  one,  and  it  reveals  sugar  in  ordinary  urines  in 
amounts  of  0.05  per  cent.,  in  concentrated  urines  only  in  amounts  of  0.1 
per  cent,  upward.  A  faint  reaction  may  be  produced  even  in  non-saccharine 
urines,  especially  when  drugs  such  as  rhubarb  and  senna,  antipyrin,  salicylic 
acid,  camphor,  chloroform,  chloral  hydrate,  saccharine,  and  turpentine  have 


886  MISCELLANEOUS. 

been  ingested.     All  of  these  substances  may  reduce  cupric  and  bismntli 
oxide  to  a  certain  degree. 

Fermentation  Test. — With  the  aid  of  a  saccharometer  we  have  a  con- 
venient method  of  estimating  the  quantity  of  sugar  in  the  urine.  A  piece 
of  yeast-cake  about  the  size  of  a  pea  is  added  to  a  test-tube  0:6  urine,  and 
allowed  to  stand  at  a  temperature  of  90°  F.  If  sugar  is  present,  yeast 
transforms  it  into  alcohol  and  carbon  dioxide,  by  fermentation.  While  this 
test  is  reliable,  it  is  not  a  rery  delicate  one. 

Blood. 

Heller's  Test. — Uriue  is  rendered  strongly  alkaline  with  potassium 
hydrate  and  boiled.  On  cooling  the  blood  coloring  matter  is  carried  down 
with  the  precipitated  earthy  phosphates  and  tinges  the  latter  (which  other- 
wise appears  as  white  ilocculi)  brownish  or  garnet  red. 

Fallacies. — Earthy  phosphates  may  be  deficient  in  the  urine  and  no 
deposit  result.    To  obviate  this  add  two  drops  of  calcium  chloride  solution. 

Certain  drugs,  as  rhubarb,  senna^  santonin,  give  a  similar  reaction. 

Guaiacnm  Test. — To  one  inch  of  urine  in  a  test-tube,  add  one  drop  of 
tincture  of  guaiacum :  the  resin  forms  a  white  precipitate.  Pour  on  to  the 
surface  one  inch  of  ozonic  ether.  If  blood  be  present,  it  and  the  ozone 
ether  together  oxidize  the  guaiacum,  and  a  blue  color  appears  at  the  jimc- 
tion  of  the  fluids. 

Fallacies. —  (1)  Pus  gives  a  similar  color,  but  it  is  more  green  than 
blue,  and  appears  more  slowly. 

(2)  Iodides  in  urine  give  a  similar  blue  color,  but  it  appears  more 
slowly  than  witli  blood. 

Pus. 

The  deposit  is  opaque  and  white;  in  small  quantities  it  may  he  mis- 
taken for  mucus ;  in  larger  C[uantities  for  phosphates  or  for  colorless  urates : 
urates  disappear  on  warming — pus  remains — phosphates  increase  with  heat, 
but  clear  up  with  acetic  acid. 

Liquor  Potassse  Test. — To  one  inch  of  the  suspected  deposit  in  a  test- 
tube  add  a  few  drops  of  liquor  potass^;  pour  the  mixture  from  one  test- 
tube  into  another.  Pus  will  have  partially  dissolved,  and  become  ropy  and 
gelatinous. 

Fallacy. — ^The  test  will  not  detect  small  cjuantities  of  pus. 

Ozonic  Ether  Test. — To  one  inch  of  the  deposit  in  a  test-tube  add  a 
few  drops  of  ozonic  ether;  on  gently  shaking,  numbers  of  small  bubbles  of 
liberated  oxygen  will  be  seen  rising  tlirough  the  fluid. 

Fallacy. — Blood  also  causes  bubbling  with  ozonic  ether. 


DIACETIO  OR  ACETOACETIC  ACID  TEST.  887 

DiACETIC    OR    ACETOACETIC    AOID    TeST. 

Gerhardt's  Iron  Chloride  Heaction. — To  one  inch  ot  urine  in  a  test- 
iiilic  add  liquor  fcrfi  j)eri(lilor  (1>.  P.)  drop  by  drop;  a  wliitc  precipitate 
of  iron  phosphate  forms  fii"st,  but  ahnost  immediately  if  acetoacetic  acid  be 
present,  the  liquid  becomes  deep  purple-red,  the  color  being  discharged 
again  on  warming. 

Acetone  Test. 

Legal's  Test. — A  few  drops  of  a  fresh  solution  of  sodium  nitroprusKside 
are  added  to  the  urine  and  a  saturated  sodium  hydrate  solution  until  a 
distinct  alkaline  reaction  is  produced.  After  the  purple  color  produced  by 
their  addition  has  been  succeeded  l)y  a  pale  yellow,  carefully  add  a  few 
drops  of  a  saturated  acetic  acid.  If  a  briglit  purple  or  carmine  color  appears, 
the  presence  of  acetone  is  proven. 

Bile  Pigments. 

Gmelin's  Test. — Upon  a  white  porcelain  slab  put  one  drop  of  the  urine 
and  close  to  it  a  drop  of  fuming  nitric  acid.  At  their  point  of  coalescence 
a  play  of  colors — yellow,  green,  red,  and  blue — will  occur  if  bile  pigments 
are  present. 

Chlokides. 

The  tests  for  chlorides  are  dependent  upon  the  formation  of  silver 
chloride  on  adding  a  solution  of  silver  nitrate  to  a  urine  previously  acidu- 
lated with  strong  nitric  acid.  This  is  to  prevent  the  formation  of  silver 
phosphate.  A  ten  per  cent,  solution  of  the  silver  salt  is  used,  and  an  exactly 
similar  test  is  to  be  made  on  normal  urine  as  a  control.  Any  reduction  in 
an  amount  sufficient  to  be  of  diagnostic  value  can  be  made  out  by,  the  dif- 
ference in  bulk  of  the  precipitate  of  silver  chloride  formed  in  the  two  test- 
tubes.    Albumin  must  be  removed  before  applying  tlie  test. 


CHAPTEE  IV. 
BACTERIOLOGICAL  [MEMORANDA.^ 

Demonsteatiox  of  Tubeeci.e  Bacilli  ix  Sputum. 

With  a  forcejos  pick  out  a  thick,  purulent  j)ortioii  of  the  sputum. 
Make  a  thin  spread  between  a  slide  and  a  cover-glass.  Allow  this  to  dry 
thoroughly  in  the  air  or  it  can  be  dried  by  holding  it  several  inches  above 
a  Bunsen  burner.  Stain  with  several  drops  of  Ziehl^s  solution  and  heat 
it  over  a  Bunsen  burner : — 

Ziehl's  solution: — 

IJ  Fuchsin    1  gram 

Alcohol    10  giams 

Carbolic  acid  5  grams 

Water    100  giams 

After  heating  wash  the  cover-glass  in  water,  and  lastly  add  several 
drops  of  Gabbet-Ernst  solution: — 

3  Methylene  blue 2  grams 

DUuted  sulphuric  acid  (25  per  cent.) 100  grams 

Einse  this  solution  off  the  cover-glass,  dry  between  filter  paper,  and 
mount  with  Canada  balsam. 

Under  the  immersion  lens  the  tubercle  bacilli  will  be  stained  red,  and 
all  other  bacteria  will  have  the  blue  background. 

Aqueous  Solutions. — Aqueous  solutions  of  methyl  violet,  gentian  vio- 
let, fuchsin,  and  the  other  aniline  dyes  are  prepared  by  adding  1  cubic  cen- 
timeter of  the  saturated  alcoholic  solutions  of  the  desired  dye  to  20  cubic 
centimeters  of  distilled  water.  This  will  impart  a  decided  color  to  the 
liquid  so  that  a  pipette  full  will  be  barely  transparent. 

The  true  aqueous  solutions  are  made  by  dissolving  the  dyes  in  water, 
but  these  are  weak  and  not  so  effective  as  those  prepared  from  the  alcoholic 
solutions.  These  solutions  deteriorate  in  a  short  time.  The  carbol-fuchsin 
and  alkaline  methylene  blue  will  keep  a  little  longer,  but  they  require  to 
be  filtered  occasionally. 

^  The  reader  is  referred  to  works  on  bacteriology  (such  as  Lenhartz-Brooks) 
for  blood  examinations  in  malaria,  ansemia,  leukaemia,  aiid  for  the  Widal  reaction 
of  the  blood  in  typhoid  fever. 

(888) 


BACTERIOLOGICAL   MEMORANDA.  889 

GONOCOOCUS. 

With  a  platinum  loop  pick  out  a  thick  purulent  portion  of  the  dis- 
charge. MaJvG  a  tliin  ppread  between  two  slides.  Drj^'  in  the  air  or  over  a 
IBiunscn  burner. 

Cover  preparation  with  aniline  gentian  violet  solution  (preferaljly 
fresh)  for  five  minutes,  pour  off  excess  of  stain  and  cover  with  Gram's  solu- 
tion for  two  to  five  minutes. 

Gram's  Solution. 

IJ   Iodine 1  gram 

Potassium  iodide   2  grams 

Distilled  water  100  grams 

Decolorized  with  95  per  cent,  alcohol  until  no  further  traces  of  the 
stain  can  be  washed  out  of  the  ^preparation.  Wash  in  w^ater  and  counter- 
stain  with  an  aqueous  contrast  st-ain,  preferably  Bismarck  brown.  Wash  in 
water,  dry  and  examine  under  oil  immersion  lens.  The  gonococci  will  take 
the  counter  stain. 

DiPLOcoccus  Pneumonia. 

With  a  platinum  loop  pick  out  a  thick  portion  of  the  sputum.  Make 
a  thin  spread  between  two  cover-glasses.  Immerse  in  a  watch—glass  of 
aniline  gentian  violet  for  ten  minutes.  Pass  through  w^ater,  and  place  in 
Gram's  iodine  solution  for  five  minutes.  Wash  in  alcohol  until  no  further 
color  comes  away.    Place  on  edge  to  dry.    Mount  in  Caaada  balsam. 

Klebs-Lokffler  Bacillus. 

Bacteriological  method  of  diagnosis  is  given  in  detail  in  chapter  on 
"Diphtheria."    Bacillus  stains  well  with  Loefflers  alkalinej  methylene  blue. 

Streptococcus. 

Usually  found  in  purulent  ear,  eye,  or  nasal  discharges,  sometimes  in 
vaginitis. 

With  a  platinum  loop  pick  out  a  thick  portion  of  the  discharge.  Make 
a  thin  spread  between  two  slides.  Dry  in  the  air  or  over  a  Bunsen  burner. 
Stain  with  methylene  blue  or  fuchsin  solution.    Mount  in  Canada  balsam. 

Meningococcus. 

Lumbar  puncture  fluid  in  cerebrospinal  meningitis  should  be  spread 
between  two  cover-glasses  and  dried  over  a  Bunsen  burner.  Stain  and 
mount  as  for  gonococcus. 


CHAPTER  V. 

ANESTHETICS  IN  CHILDREN. 

NiTEOUs  Oxide  and  Ether. 

The  ideal  anesthetic  for  children  is  a  combination  of  nitrons  oxide 
and  ether.  Whenever  it  is  possible  one  skilled  in  its  administration  should 
he  employed.  The  responslMlity  of  attending  to  a  major  or  minor  opera- 
tion is  so  great  that  unless  one  shilled  in  the  administration  of  an  ances- 
thetic  is  employed  there  may  be  serious  after-effects.  To  properly  guard 
the  heart  and  respiration  requires  experience,  and  no  surgeon  should  un- 
dertake to  do  both,  excepting  in  extreme  emergencies. 


Fig.    300. — Gas  and  Ether  Inhaler. 


Walter  K.,  5  years  old,  was  given  a  mixture  of  nitrous  oxide  and  ether  by  Dr. 
Culler.  The  child  was  anaesthetized  without  a  struggle.  I  removed  the  adenoids 
and  hypertrophied  tonsils.  The  child  showed  no  evidence  of  shock.  There  was 
slight  nausea.  No  other  evidence  of  gastric  disturbance.  There  were  no  after- 
effects. 

Chlorofoem. 

Chloroform  vapor  is  decomposed  into  chlorine  and  hydrochloric  acid 
by  the  presence  of  the  common  gas  flame,  and  may  thus  give  rise  to  irri- 
tating effects  upon  the  respiratory  organs. 
(890) 


ANiESTHETICS.  891 

When  employed  it  should  be  administered  by  the  drop  method.  By 
this  method,  combined  with  fresh  air,  the  danger  is  miiiijuized.  The  statis- 
tics of  Dr.  George  Gould,  of  Philadelphia,  and  the  Lancet  Commissioner, 
prove  that  chloroform  anassthesia  causes  more  deaths  than  ether  as  an 
anaesthetic. 

Ethyl  Chloride. 

This  is  an  excellent  anaesthetic  and  can  be  administered  as  a  spray  on 
a  chloroform  mask.  I  have  frequently  used  it  in  my  hospital  service  to 
remove  adenoids,  tonsils,  and  for  a  circumcision.  Ethyl  chloride  is  a  rapid 
and  safe  anaesthetic. 

Local  AmvstJiesia. — Ethyl  chloride,  as  a  spray,  until  the  part  is  frozen, 
is  sufficient  to  open  an  abscess,  for  a  lumbar  puncture,  or  even  an  empyema, 
in  a  sensitive  child  or  where  general  anaesthesia  is  contraindicated. 

The  inhalation  of  ethyl  chloride  is  also  of  great  advantage  where 
a  short  ancestliesia  is  required,  as,  for  instance,  when  a  paracentesis  of  the 
ear  is  to  be  made.  An  advantage  of  ethyl  chloride  over  ether  or  chloroform 
is  that  it  is  not  followed  by  nausea  or  vomiting. 

Ether. 

Sulphuric  ether,  used  alone  as  an  anaesthetic  in  children,  may  be 
considered.  It  requires  a  much  longer  time  to  produce  its  effect, 
although  it  has  no  depressing  effect  upon  the  heart.  Statistics  show  that 
in  300,175  administrations  of  ether  there  were  18  deaths.  Out  of  638,461 
of  chloroform,  there  were  160  deaths,  showing  the  following  ratio : — - 

Chloroform  mortality   1  to     3,749 

Ether  mortality    1  to  16,675 

We  therefore  see  that  ether  is  by  far  the  safer  anaesthetic.  Weir  states 
that  "ether  narcosis  is  safer,  even  though  the  kidneys  are  slightly  affected.'' 
Ether  is  frequently  combined  with  oxygen,  and,  as  previously  stated,  with 
laughing  gas,  and  forms  in  the  latter  combination  flie  safest  aiiasthdic  for 
children. 

Regarding  the  Effect  of  Ether  in  Affections  of  the  Air  Passages. — 
Affections  of  the  air  passages  following  ether  narcosis  are  usually  the  result 
of  aspiration  of  infected  mouth  contents.  Ether  causes  a  slight  increase  of 
mucous  secretion.  It  has  no  irritant  action  on  the  tracheal  or  bronchial 
mucous  membrane.  When  bronchitis  or  pneumonia  exists,  greater  care 
must  be  taken  owing  to  the  increased  secretion  produced  by  the  ether,  as 
stated  above.  When  nitrous  oxide  is  given  we  avoid  the  irritant  effect  just 
described. 

In  adenoid  operations,  give  nitrous  oxide  until  cyanosis  is  seen,  then 
give  ether ;  the  change  relieves  cyanosis  at  once. 


892  MISCELLANEOUS. 

Lymphatic  Enlargement  in  Children. — Most  deaths  occur  in  children 
in  which  the  lymphatic  condition  exists — ^the  so-called  lymphatic  diathesis. 

The  Children's  Clinic  at  Graz.  during  the  last  twenty  years^  shows 
that  records  of  fatalities  with  chloroform  always  revealed  the  lymphatic 
hyperplasia,  which  is  the  principal  feature  of  the  so-called  constitntio  lym- 
phatica.     (Eead  chapter  on  "Status  Lymphaticus.") 

Ewing  believes  the  above  conditions  prevail  in  America.  Lartigan's 
report  of  the  Eoosevelt  Hospital  shows  that  death  came  after  ether  as  well 
as  after  chloroform,  in  children  affected  by  the  lymphatic  constitution. 

The  presence  of  universal  enlargement  of  the  hmph  nodes  without 
direct  inflammatory  cause,  hypertrophied  tonsils,  adenoid  hyperplasia, 
tendencies  to  ansemia.  weakness  of  pulse,  irregular  heart's  action,  along 
with  insufficient  development  of  the  heart  and  large  blood-vessels,  show 
that  the  lymphatic  condition  exists. 

Local  or  Ixtea-spixal  Ax^sthesia.^ 

Corning,  of  Xew  York,  about  twenty  years  ago  found  that  anesthesia 
could  be  produced  in  the  lower  part  of  the  body  by  injecting  cocaine  in  the 
lumbar  region  of  the  spine.  The  patient  is  placed  in  a  sitting  position 
well  bent  forward,  and  firmly  held  during  the  injection.  The  skin  should 
be  cleaned  in  the  usual  antiseptic  way,  followed  by  an  ethyl  chloride  spray. 
This  renders  the  introduction  of  the  needle  practically  painless.  A  point 
one-half  inch  to  either  side  of  the  median  line  and  midway  between  the 
spinous  process  is  taken,  and  the  needle  pushed  forward,  inward,  and 
upward.  Special  effort  is  made  to  keep  away  from  the  central  part  of 
the  spinal  canal  by  a  close  relation  of  the  needle  point  to  the  dura.  The 
instrument  used  is  of  the  simplest  kind.  A  small-sized,  steel  aspirating 
needle  with  a  short-beveled  pointed  end,  having  a  well-fitted  hjrpodermic 
barrel,  answers  every  purpose.  As  nearly  as  possible  the  same  amount  of 
cerebro-spinal  fluid  is  allowed  to  escape  as  of  the  injection  medium  which 
is  to  he  introduced.  The  injection  is  given  slowly,  usually  taking  one  and 
one-half  to  two  and  one-half  minutes.  Often  the  flrst  evidence  that  the 
cocaine  is  taking  effect  is  some  dilatation  of  the  pupils  or  a  slight  nausea. 

Since  the  introduction  of  novocaine  we  have  a  much  safer  local  anses- 
thetic.  Owing  to  its  being  less  toxic  than  cocaine  we  do  not  have  the  dis- 
agreeable constitutional  s}'mptoms  so  prevalent  during  the  administration 
of  cocaine.  There  is  an  absence  of  nausea  and  vomiting  and  an  absence  of 
the  dilatation  of  the  pupils. 

The  clinical  researches  of  Braun  and  Bier  have  demonstrated  that 
novocaine    produces   more    profound    and   more   lasting    anaesthesia   than 


*  The  technique  of  lumbar  puncture   is    described  in  article   on   "Aleningitis" 
(page  789). 


ANESTHETICS.  893 

cocaine.  When  applied  locally  it  has  no  irritating  qualities.  From  one- 
half  to  1  cubic  centimeter  of  the  1  per  cent,  novocaine-suprarenin  was  suf- 
ficient to  procure  complete  anaesthesia  for  four  hours. 

Novocaine  when  combined  with  suprarenin^  offers  our  best  means  of 
producing  local  anaesthesia.  This  combination  produces  far  less  toxicity 
than  cocaine.  It  is  dispensed  in  tablet  form  and  is  readily  soluble  in 
water.    Novocaine  produces  no  by-effects  and  causes  no  mydriasis. 

This  method  has  been  especially  valuable  where  circumcision  is  to  be 
performed,  or  where  the  examination  of  the  bladder  is  to  be  made.  In 
children  I  have  frequently  found  considerable  nausea  and  vomiting  fol- 
lowing the  use  of  cocaine;  the  same  is  also  true  of  eucaine.  The  analgesic 
effect  of  eucaine  is  in  some  cases  as  good  i  as  that  of  cocaine. 

Dose  Bequired. — Five,  rarely  10  minims  of  freshly  prepared  2  per 
cent,  cocaine  solution  are  required.  The  solution  should  be  freshly  pre- 
pared for  each  case,  by  dissolving  the  eucaine  or  cocaine  in  sterile  water. 
It  is  well  to  remember  that  there  are  certain  toxic  effects  noted  in  some 
children.  This  should  be  borne  in  mind,  and  individual  idiosyncrasies 
noted. 


^  Novocaine  tablets  can  be  procured  in  various  strengths  through  Farbwerke 
Hoechst  Co.,  New  York. 


CHAPTEE  VI. 

DISINFECTION. 

The  modern  conception  of  the  transmission  of  such  infectious  diseases 
as  diphtheria,  scarlet  fever,  measles,  and  cerebro-spinal  meningitis  has  re- 
sulted in  a  complete  reversal  of  the  methods  of  fumigation,  isolation,  and 
quarantine.  The  Health  Department  of  the  city  of  New  York  has,  as  recent 
as  July,  1913,  i-ssued  orders  that:  "On  account  of  the  practical  absence  of 
danger  from  bedding  used  by  the  patient,  the  removal  of  such  bedding  for 
disinfection  after  the  termination  of  cases  of  diphtheria,  scarlet  fever, 
measles,  cerebro-spinal  meningitis  and  poliomyelitis  should  be  discontinued. 
In  exceptional  instances  where  the  family  or  physician  insist  upon  steriliza- 
tion of  bedding,  it  will  still  be  performed  by  the  department.  In  special 
cases,  where  proper  and  efficient  fumigation  cannot  be  performed  by  reason 
of  the  nature  of  the  premises,  bedding  will  be  removed  after  the  termination 
of  these  diseases,  and  bedding  will  also  be  removed  in  cases  of  small-pox." 

The  best  disinfectant  is  sunlight  and  fresh  air.  There  is  no  danger 
from  the  air  of  the  room  in  which  the  patient  suffering  from  diphtheria  is 
confined.  There  is  danger  in  the  secretions  from  the  nose  and  mouth,  or  i£ 
there  is  a  mouth  to  mouth  contact  with  a  patient  suffering  from  diphtheria. 

The  'presence  of  insects  in  the  sicTc  room,  especially  flies,  should  be 
guarded  against  as  much  as  possible,  in  view  of  the  fact  that  they  may 
act  as  carriers  of  the  disease.  No  food  should  be  allowed  to  stand  uncov- 
ered in  the  sick  room,  as  in  certain  cases  pathogenic  organisms  may  gain 
access  and  multiply  therein. 

Sputa  are  best  disinfected  by  steam  sterilization,  together  with  the 
sputum  cups.  The  addition  of  15  grams  of  sal-soda  to  a  liter  of  water 
materially  aids  the  process  of  cleaning. 

TJrine  and  fceces  are  best  treated  together  by  means  of  milk  of  lime. 
In  this  we  possess  the  most  valuable  agent  for  the  disinfection  of  typhoid  and 
cholera  stools.  This  agent  is  prepared  as  follows:  To  unslacked  lime, 
placed  in  a  jar,  as  much  water  as  it  will  absorb  is  added.  The  unslacked 
lime  is  stirred  up  with  4  parts  of  water  to  form  the  milk  of  lime,  and 
this  is  mixed  intimately  with  the  discharges  until  the  mixture  gives  a  strong 
alkaline  reaction  (tested  by  litmus  paper). 

Chloride  of  lime,  to  be  effective,  must  contain  25  per  cent,  of  avail- 
able chlorine.  Six  ounces  to  the  gallon  of  water  represents  the  standard 
solution. 

Carbolic  acid,  unless  in  combination  with  sulphuric,  and  corrosive 
sublimate  are  not  suitahle  for  the  disinfection  of  stools. 

Discharges  can  also  be  disposed  of  by  burning  after  being  mixed  with 
sawdust. 

Water-closets  are  best  disinfected  by  chloride  of  lime  solution. 
(894) 


CHAm^ER  VTT. 

THE  ADMINISTRATION  OF  DRUGS  TO  CHILDREN. 

A  FEW  points  concerning  the  use  of  drugs  in  children  should  he 
noted : — 

1.  Give  the  minimum  dose  of  a  drug  in  the  heginning  of  a  disease. 

2.  Administer  the  drug  in  a  palatable  form. 

3.  The  soluble  tablet  triturates  should  be  administered,  as  they  com- 
bine a  minimum  quantity  with  solubility  and  palatability. 

4.  Remember  the  idiosyncrasies  of  drugs  and  guard  against  toxic  doses 
by  watching  the  effect  of  a  drug  in  any  given  case. 

5.  In  some  specific  diseases  such  as  diphtheria,  give  a  sufficient  quan- 
tity of  antitoxin  to  obtain  a  therapeutic  result. 

6.  Certain  drugs,  for  example,  belladonna,  calomel,  quinine,  strych- 
nia, bromoform,  and  alcohol,  tvJien  cautiously  administered  can  be  given 
in  very  large  doses.  It  is  only  necessary  to  note  the  physiological  effect 
and  then  to  give  the  drug  until  its  point  of  tolerance  is  reached. 

Accuracy  in  dealing  with  poisons  is  very  important  in  children.  It 
is  surprising  to  see  the  difference  in  size  of  various  teaspoons  on  the  market. 
I  advise  using  a  medicine  glass,  which  is  graduated  with  teaspoon,  etc. 


(895) 


CHAPTER  VIII. 
LOCAL  REMEDIES. 

Cold  Compresses. 

Cold  compresses  may  be  made  out  of  linen  or  cheese-clotli  folded  sev- 
eral times  and  wrung  out  in  ice-water.  If  there  is  any  abrasion  of  the 
skin,  1  part  of  glycerine  should  be  added  to  every  5  parts  of  water.  If  con- 
stant cold  is  wanted,  compresses  should  be  changed  frequently. 

Hot  Compresses  ok  Fomentations. 

Hot  compresses  or  fomentations  are  made  by  wringing  out  a  piece 
of  flannel  in  hot  water.  As  this  is  oftentimes  hotter  than  the  hands 
can  stand,  the  flannel  may  be  placed  in  a  towel,  two  ends  being  kept  from 
the  water  and  then  wrung  out  in  the  towel  by  twisting  the  ends.  In  apply- 
ing fomentations  they  should  not  be  hotter  than  can  be  borne  by  the  face 
of  the  mother  or  nurse.  To  retain  the  heat  they  may  be  covered  with  oil 
silk,  oil  paper,  or  oiled  muslin,  and  then  with  a  dry  towel.  Eenew  when 
cool. 

Poultices. 

A  poultice  is  intended  to  supply  heat  for  a  greater  period  than  a 
fomentation.     It  should  not  be  more  than  one-half  inch  in  thickness. 

A  flaxseed  poultice  is  made  as  follows;  A  sufficient  quantity  of 
water  is  heated,  and  when  brought  almost  to  the  boiling  point,  the  flaxseed 
meal  should  be  added  slowly,  stirring  all  the  while  to  avoid  lumping. 
The  meal  may  be  added  until  it  has  the  consistency  of  hot  mush, 
too  thick  to  flow.  This  may  be  spread  on  a  piece  of  linen  or  cotton 
cloth,  the  edges  turned  over  slightly  and  the  part  to  which  it  is  to  be 
applied  next  to  the  body  must  be  covered  with  an  old  handkerchief  or 
thin  piece  of  linen.  See  that  it  is  not  hot  enough  to  burn  the  skin. 
The  poultice  should  be  larger  than  the  affected  area.  Afterward  cover 
with  oil  silk  or  paper  to  keep  out  the  air,  and  then  bandage  in  place.  This 
can  be  renewed  every  hour  or  so.  Have  everything  ready  when  the  poul- 
tice is  made,  as  it  quickly  cools  when  exposed  to  the  air. 

Turpentine  Stupes. 

Turpentine  stupes  are  found  very  useful  in  cases  of  abdominal  pain. 
A  piece  of  flannel  is  wrung  out  in  hot  water,  the  same  as  in  a  fomentation, 
(896) 


LOCAL  REMEDIES.  897 

except  a  little  soap  or  oil  added  to  the  water.  A  little  turpentine  should 
then  be  sprinkled  evenly  over  the  surface  of  the  llaund,  about  oO  drops  to 
each  square  foot  or  a  teaspoonful  may  be  added  to  the  water.  Apply  the 
same  as  a  fomentation. 

Mustard  Plasters. 

Mustard  plasters  for  infants  should  be  made  with  1  part  of  mustard 
to  3  or  -1  parts  of  flour  or  flaxseed  meal.  Add  warm  water  and  stir  until 
of  the  proper  consistency.  Spread  thinly  on  a  cloth  and  apply  directly  to 
the  skin.    It  is  to  be  kept  on  until  the  skin  is  reddened,  not  blistered. 

Ginger  Poultice. 

Ginger  poultice  is  made  in  the  same  way  as  that  described  for  the 
making  of  mustard  plasters,  and  has  its  advantages  in  that  it  will  not 
blister. 

Cantharidal  Collodion. 

In  using  the  cantharidal  collodion  care  should  be  exercised  to  remove 
all  moisture  and  excretions  from  the  skin  before  applying,  otherwise  the 
cantharidin,  being  soluble  in  water,  will  not  come  into  contact  with  the 
skin.  One  of  the  most  convenient  methods  of  preparing  the  skin  for  the 
application  of  cantharidal  collodion  is  to  wash  the  part  with  vinegar  or 
dilute  acetic  acid. 

Venesection  (Blood  Letting). 

Local  hJood  Jetting  is  frequently  a  valuable  therapeutic  aid,  especially 
in  meningitis  and  in  cerebral  pneumonia,  in  fact,  wherever  symptoms  of 
cerebral  hypersemia  are  noted.  Convulsions  are  sometimes  prevented  by 
relieving  congestion  with  the  aid  of  a  few  leeches.  Baginsky  reports  the 
value  of  venesection  as  a  routine  measure  in  certain  types  of  diseases,  such 
as  continued  convulsions,  in  which  relief  can  be  afforded  by  this  means. 
The  skill  of  the  surgeon  is  necessary,  for  we  must  consider  the  possibiKty 
of  infection  while  opening  a  vein. 

Dry  Cupping. 

The  application  of  dry  cups  is  useful  in  marked  dyspnoea.  It  is  there- 
fore indicated  in  asthma,  broncho-pneumonia,  and  in  pulmonary  oedema, 
t\\o  cups  may  be  applied  on  each  side  posteriorly  for  several  minutes.  If 
relief  is  afforded,  they  can  be  applied  once  every  twelve  hours. 


B7 


CHAPTEE  IX. 
RECTAL  :SIEDICATIOX  IX  CHILDREN. 

TThex  the  stomach  is  irritable  in  3'ouiLg  children  I  prefer  to  medicate 
per  rectum.  The  gastric  mucous  membrane  will  sometimes  show  an  in- 
tolerance for  drugs.  It  is  advisable,  especially  in  exhaustive  diseases,  such 
as  diphtheria,  t^-phoid  fever,  and  the  intestinal  disorders,  to  support  the 
strength  of  the  body  with  nutrition.  In  such  cases  vomiting  may  be  pro- 
voked by  the  administration  of  drugs.  Children  will  frequently  object  to 
taking  medicine,  and  it  is  painful  to  watch  the  struggle  between  mother 
and  child  while  attempting  to  force  the  medicine  into  the  infant's  mouth. 
In  such  cases,  especially  in  very  j'oung  infants  with  whom  we  cannot  reason, 
the  rectum  should  be  chosen  as  the  proper  charmel  for  the  introduction  of 
the  drug.     The  rectum  absorbs  slowly  but  sureh'. 

The  following  drugs  may  be  given  per  rectum  and  the  doses  gradually 
increased : — 

Aconite  may  be  given  in  suppository,  but  shows  its  action  only  in  large 
doses.  We  must  therefore  administer  it  in  repeated  small  doses  to  obtain 
its  effect.  For  example,  we  may  give  1  or  2  drops  of  the  tincture  in  a 
suppository-  to  a  year-old  child. 

Belladonna  acts  as  an  excellent  sedative  in  cough,  and  exerts  a  very 
favorable  influence  on  the  m-uscle  fiber  of  the  intestine.  We  may  use  ^/g 
minim  of  extract  of  belladonna  in  twenty-four  hours,  divided  into  three 
or  four  suppositories,  for  every  two  years  of  age. 

Bromides  r^hould  be  given  in  doses  of  3  grains  for  each  year  of  life,  in 
two  suppositories:  '/^  grain  if  it  is  to  be  continued.  In  severe  spasm  we 
may  give  two  grains  for  each  year  of  life,  in  two  suppositories  rapidly  fol- 
lowing each  other;  for  example,  in  laryngismus  stridulus. 

Caffeine  is  usually  injected  subcutaneously.  It  may,  however,  be 
administered  in  a  suppository  with  equal  parts  of  benzoate  of  sodium. 
For  example,  one  and  one-half  grains  to  a  suppository,  using  two  daily 
for  each  year  of  the  child's  life. 

Digitalis. — Powdered  digitalis  is  with  difficulty  absorbed  by  the  rec- 
tum. The  tincture  should,  therefore,  be  used.  The  maximum  dose  for 
each  year  of  life  is  4  drops,  divided  into  two  suppositories. 

Iodine  and  its  preparations  are  exceptionally  well  borne  by  the  rectum, 
and 'fully  absorbed.     Three  grains  for  each  year  of  life,  in  two  supposi- 
tories, is  the  maximum  dose;  ^/^  grain  if  it  is  to  be  continued. 
(898) 


RECTAL  MEDICATION.  899 

Mercury  should  only  exceptionally  be  given  per  rectum,  and  then  only 
in  tiio  i'oriM  of  calomel,  ''/^  grain  in  a  suppository  for  each  year  of  life. 

Nux  Vomica. — One-sixth  of  a  grain  for  every  two  years,  in  three  sup- 
positories. 

Strychnine  should  only  l)e  given  to  children  over  10  years  of  age. 

Salicylic  Acid. — Seven  and  three-quarter  grains  for  each  year  of  life^ 
in  divided  doses   (three  or  four). 

Quinine  is  best  given  in  suppositories.  The  daily  maximum  dose  is 
2  to  3  y.j  grains,  in  two  suppositories,  for  each  year  of  life. 

Antipyrine  may  be  given  in  the  same  dose  as  quinine. 

Opium. — Pulvis  opii  may  be  given  in  suppositories,  in  doses  of  Voo 
grain  for  each  year  of  the  child's  age,  and  this  dose  may  be  repeated  in 
s-evere  cases  every  two  hours. 

Toxic  symptoms  should  be  carefully  watched  for,  and  the  use  of  the 
remedy  discontinued  on  their  appearance.  These  doses  are  small  ones  and 
may  be  increased. 


CHAPTEE  X. 
PRESCRIPTIONS  FOR  VARIOUS  DISEASES.- 

Feveb. 

I^   Sweet  spirit  of  niter   l^^  fl.  draclims  6|0 

Citrate  of  potassium   30  grains  2j 0 

Syrup  of  lemon    4  fl.  drachms  15  0 

Aquse   q.  s.  ad     2  fl.  ounces        q.  s.  ad  60  0 

M.     Sig. :    A  teaspoonful  every  hour.     Repeat  3  doses. 

For  a  child  3  years  old;  younger  children  y^  teaspoonful. 

5  Tr.  aconite  rad 16  drops  gtts.   16] 

Spir.  mindererus    2  ounces  60  [  0 

M.     Sig.:      %   teaspoonful  every  hour. 
For  a  child  2  to  4  years  old. 


To    COBBECT    FLATUI.ENCE — ^A   iMiLl)    LAXATIVE. 


Vf,  Magnesia  usta    1  drachm  4 

Pulv.  rhei   1  drachm  4 

Saccharum    2  grains  0 

M.   and  divide   into   12   powders. 

Sig.:    1   powder  in  a  teaspoonful  of  water  every  two  or  three  hours 


Pebsistent  Diaebhea,  with  Tubekcuiab  Symptoms. 

IJ  Guaiacol  carbonate. 

Sig. :     1  to  2  grains  three  times  a  day. 

For   a   child   1   year  old. 


Entebo-colitis. 

R  Tinct.  kino   20  minims  gtts.   20 1 

Misturse  cretse  comp 1  drachm  4|0 

Aqua q.  s.  ad     2  ounces  q.  s.  ad  60  0 

M.     Sig. :      Teaspoonful  every  three  hours. 


Colitis,  with  Pain. 

IJ  Tinct.  opii  camph 10  minims 

Bismuthi   subnit 2  grains 

Aquae  calcis q.  s.  ad     4  drachms 

M.      Sig.:      Teaspoonful   every   two   hours. 
(900) 


gtts.   10 
0 

12 

q.   s.   ad   16 

0 

PRESCRIPTIONS. 


901 


M, 


Atonic  Dyspepsia,  with  Constipation. 

Tinct.  nucis  vomicae 15  minims 

Pulv.  rad.  ipecacuanhae  1  grain 

Pulv.  rad.  rhei    10  grains 

Sodii  bicarbonas    %  drachm 

Aquae   q,  s.  ad  2  ounces 

Sig. :     Teaspoonful  before  each  feeding. 


gtts,  15 

0 

06 

0 

6 

2 

0 

s.  ad  30 

0 

SUMMEE  DiABBHEA. 

IJ  Calomel  tablets   Vio   grain 

Sig.:    1  every  twenty  minutes  for  three  doses. 
For  a  child  1  to  2  years  old. 

Followed  by: — 

IJ  Mist,  rhei  et  soda 2  ounces 

Sig.:     Teaspoonful  every  hour,  for  three  doses. 

Following  day  give:  — 

IJ  Bismuth  betanaphthol. 

Sig.:     5  grains,  in  water,  every  two  hours. 

Or:— 

B  Mist,  creta. 

Sig.:     Teaspoonful  every  two  hours. 

Or:— 

R  Bismuthi   subnit 20  grains 

Misturse  cretse  comp 4  drachms 

Aquae  q.  s.  ad    2  ounces 

M.     Sig.:     Teaspoonful  every  two  hours. 

Or:— 

R  Tannalbin  or  tannigen. 

Sig.:    5  to  10  grains  every  three  hours. 


01006 


3010 


1 
16 

s.  ad  30 


Beoncho-pneumonia. 

R  Sodium   benzoate    V^  drachm 

Liq.  ammon.  anisat 1  drachm 

Syr.  prun.  virgin 1  ounce 

Aquae q.  s.  ad     2  ounces 

M.     Sig.:     Teaspoonful  every  two  hours. 

For  child  5  years  old. 


2|0 

4|0 

3G|0 

ad  6010 


902  MISCELLANEOUS. 

Capillaby  Bbonchitis. 

When  expectoration  is  viscid: — 

IJ  Ammon.  carbonat 10  grains  0 

Syr.  senega    4  drachms  16 

Syr.  prun.  virg 6  drachms  24 

Aquae  camph q.  s.  ad    2  ounces  q.  s.  ad  60 

M.     Sig. :     Teaspoonf ul  in  water,  every  two  hours. 


Acute  Cataeehal  Bbonchitis. 

IJ  Ammon.  muriat 15  grains  1 

Ammon.  bromid 20  grains  1 

Syr.    liquorit 6  drachms  24 

Tinct.  opii  camph 2  drachms  8 

Aquae  q.  s.  ad    2  ounces  q,  s.  ad  60 

M.     Sig.:      Yo  teaspoonful  every  two  hours. 


Stimulating  Expectobant. 

I^    Syr.    senegse     20  drops 

Ammon.  carbonat %  drachm 

Tinct.  opii  camphorat 3  drachms 

Syr.  tolutan 5  drachms 

Aquse  q,  s.  ad     6  ounces 

M.     Sig.:      Teaspoonful  in  water  every  two  or  four  hours. 


gtts.   20 

2 

0 

12 

0 

20 

0 

q.  s.  ad  180 

0 

'    •  Pleubisy. 

For  cough  with  pain  on  breathing: — 

I^  Pulv.  Doveri 10  grains  016 

Pulv.  ext.  liquorit. 20  grains  13 

Sacch.  albi  30  grains  2|0 

M.  ft.  chart,  no.  xx. 

Sig.:     1  powder  every  three  hours. 


Pneumonia. 


Reduce  fever  with  tepid  baths  or  packs. 

Daily, attention  to  bowels  with  calomel  or  enema. 

IJs:  Tinct.  aconite,  1  drop  every  hour,  until  fever  is  reduced. 

Aid  rest  at  night  with: — 

IJ  Codeine,  Vio  grain.    Repeat  in  three  hours  if  necessary. 

Or:— 

IJ  Dover's  powder,  %  to  1  grain.    Repeat  in  three  hours  if  necessary. 


PRESCRIPTIONS.  903 

Erysipelas. 
Streptococcus  vaccine,  50,000,000  to  100,000,000.     Inject  \>y  hypodermic. 


Bactebial  Vaccines. 

Vaccine    treatment    for    erysipelas,    pertussis,    typhoid,    and    pneumonia,    will 
be  found  on  pages  450-454. 


Gastro-enteeitis. 
IJ  Castor  oil. 

Teaspoonful  every  two  hours,  for  four  doses. 

If  diarrhea   persists  after   flushing  the  colon   and  washing  the   stomach,   give 
the    following: — 
I^  Eudoxine. 

Sig. :     5  grains  every  three  hours. 
The  diet  is  most  important. 


Persistent  Vomiting. 

Lavage  (stomach  washing)  with  one  tablespoonful  of  salt  to  a  quart  of  warm 
water   (100°  F.).     Then  leave  stomach  rest  at  least  six  hours. 


Mouth- WASH. 
Pulv.  acid,  boric  solution,   1   per  cent. 


Stomatitis  or  Aphthae. 

R;  Solut.  kali  permangan.,  1  per  cent. 

Sig. :     Dilute  with  equal  parts  warm  water.     Wash  three  times  a  day. 


Enuresis. 


R  Ext.  rhus  aromaticse  fl 10  minims  gtts.   10 

Syrupi  aromatici    20  minims  gtts.   20 

Aquse  destillatse    q.  s.  ad     1  drachm  q.  s.  ad    4 

Sig.:      This   amount   to  be  given   three   times   a   day. 

Or:  — 

R   Liq.  stryehninse  hydrochloratis   45  minims  gtts.  451 

Liq.  atropinae  sulphatis  1^2  drachms  6J0 

Syr.  aurant q.  s.  ad     1  ounce  q.  s.  ad  3010 

Sig.:   5    drops   at   night.      Increase   gradually. 

For  a  child  14  years  old.     Younger  children  in  proportion. 


904  ]inSCELLANEOUS. 

Hookworm. 

R  Eucalyptus  oil  2  drops  gtts.   2 

Clilorofomi 1  drop  gtt.  1 

Castor  oil   2  drachms  8 

M.     Sig. :    One  dose  t.  i.  d.     Eepeat  treatment  several  days. 

Tapewoem. 

5   Chloroform 10  drops  gtts.   10 

Oleores.  filis  mas 1%  drachms  6 

Syr.  ginger  q.  s.  ad     1  ounce  q.  s.  ad  30 

Nepheitis. 

IJ  Potass,  citrat 2^2  drachms  10 

Est.  buchu  fl 2%  drachms  10 

Ext.  uva  ursi  fl 1  drachm,  1  scruple  5 

Syr.  limonis  2  ounces  60 

Aquse   q.  s.  ad  4  ounces             q.  s.  ad  120 

M.     Sig. :     Tea  spoonful  every  two  to  three  hours. 


Pebtussis. 
IJ  Phenacetine. 

Sig.:     2  to  5  grains  every  three  hours,  by  day. 

ij^  Codeine. 

Sig.:     Vs  grain  gradually  increased  to  ^  grain,  every  two  to  three  hours,  at 
night,  until  cough  lessens. 

In  severe  cases: — 

IJ  Heroin. 

Sig.:    V21  grain,  given  at  night.     Repeat  in  two  hours. 


J.IEASI.ES. 
Pre-eruptive   stage: — 
Hot  bath  or  dry  hot  blanket  pack. 

IJ  Spiritus  mindererus    (freshly  prepared). 
Sig. :     1  drachm,  in  water,  every  hour. 

When   eruption   appears: — 

Continue  warmth  and  warm  drinks. 

Strict  attention   to  bowels. 

For  cough   (see  I^  Acute  Catarrhal  Bronchitis), 


PRESCRIPTIONS. 


905 


Or:— 

IJ  Ammon.  bromid 45  grains 

Syr.  liquorit 6  drachms 

Decoct.  althfE  q.  s.  ad     2  ounces 

Sig. :      Teaspoonful   every   hour,    until   relieved. 

For  a  child  1  year  old. 


310 
25|o 

q.  s.  ad  6010* 


Scarlet  Feveb. 

To  reduce  fever:  — 

IJ  Tinct.   aconiti    20  drops 

Spir.  mindereri  2  ounces 

Syr.   limonis    1  ounce 

M.     Sig.:     Teaspoonful  every  hour,  until  sweating  is  produced. 

For  a  child  5  to  12  yeafs  old.     Younger  children,  half  the  dose 

Itching:  — 

R  Calamine     1  drachm 

Ung.  aq.  rosse   1  ounce 

M.  et  ft.  ungt. 

Sig.:      Apply  over  body  once  or  twice  a  day. 

Stimulant: — 

R  Camphor     1  gramme 

Olive  oil   10  grammes 

Sig. :     Use  hypodermically. 


gtts.  20 
60 
30 


I 


Restoratives: — 

R  Mist,  ferri  et  ammonii  acetatis, 

Glycerini    aa  1  fl.  ounce  aa  30 

Aquae    q.   s.  ad  4  fl.  ounces       q.  s.  ad  120 

M.     Sig.:     A  teaspoonful  or  more,  in  water,  every  three  hours. 

Or  Basham's  Mixture  may  be  given: — 

R  Tinct.   ferri   chloridi, 

Acidi  acetici   dil aa  1  fl.  drachm  aa  4 

Liq.  ammonii  acetatis   6  fl.  drachms  24 

Aquae    q.   s,  ad  6  fl.  ounces       q.  s.  ad  180 

M.     Sig.:     Tablespoonful  three  times  a  day. 

For  a  child   6  years  old. 


ScAELET  Fever — Nephritis. 
(Diuretic.) 
R  Acet-theocine. 
Sig.:     5  to  10  grains,  every  three  hours. 


Vaginitis  Following  Scarlet  Fever. 

R  Solut.  argyrol,  25  per  cent. 

Sig.:    Drop  a  few  drops  into  vagina  with  medicine  dropper,  two  or  three  timei? 


a  da^. 


906  MISCELLANEOUS. 

Simple  Vaginitis. 
Iji  Alum,  powdered 1  ounce  301 0 

Or:  — 

IJ  Zinc   sulphate    1  ounce  30 1 0 

Or:— 

IJ  Borax 1  ounce  30 1 0 

Sig. :     A  tablespoonful  to  a  quart  of  water,  to  be  used  as  a  vaginal  injection 

three  or  four  times  a  day.    Apply  a  sterile  pad  of  cheese-cloth.     A  fresh  pad  to  be 

applied  after  each  irrigation. 


Tonic  Aftee  Exhaustive  Disease,  Such  as  Pneumonia  oe 

SUMMEE   DiAEEHEA. 

IJ   Ferri  pyrophos 1  drachm 

Quininse  sulph %  drachm 

Strych.  sulph ^,  grain 

Acid,  phosph.  dil 2  drachms 

Aquse    q.   s.  ad    4  ounces 

M.     Sig.:   Teaspoonful  three  times  a  day. 


4 

0 

2 

0 

0 

015 

8 

0 

q.  s.  ad  120 

0 

Tonic  and  Restoeative. 

I^  Ferri  et  quininse  citrat %  drachm  2 

Syr.  hypophos.  comp 4  drachms  16 

Aquse    q.   s.  ad    2  ounces  q.  s.  ad  60 

M.      Sig.:      Teaspoonful    after   each   meal. 


Tonic  Dueing  Choeea. 

IJ  Liq.  potass,  arsenitis   %  drachm 

Ferri  et  ammon.  citrat 1  drachm 

Aquse    q.   s.   ad     2  ounces 


q.  s. 


2 

4 
ad  60 


M.     Sig.:     Teaspoonful  three  times  a  day.     Increase  gradually. 


To  Aboet  Acute  Tonsillitis. 

IJ  Creosote    8  drops 

Tinct.  myrrh 2  ounces 

Glycerini  2  ounces 

Aquse  4  ounces 

M.      Sig.:      Gargle  every  hour. 


Acute  Tonsillitis. 

I^  Tinct.  aconit.  rad 1  ounce 

Sig.:      I  drop  every  hour   for   six  doses. 
For  a  child  1  to  5  vears  old. 


gtts,   8 

60 

60 

120 


3010 


PRESCRIPTIONS. 

Milk  Cbust. 

I^  Olive  oil    %  ounce 

Castor  oil  %  ounce 

Salicylic   acid    %  drachm 

M.     Sig. :     Apply  every  six  hours  until  the  crusts  loosen. 


907 


Eczema  Rubbum. 

Salicylic-sulphur   paste: — 

IJ  Ac.    salicyl.    15  grains 

Sulph.   depur 1  drachm,  1  scruple 

Petrolati   6  drachms 

Zinci  oxidi   2%  drachms 

Amyli    2^4  drachms 

M.     Sig. :      Apply  three  times  a  day. 

Ichthyol  ointment: — 

IJ  Ammon.  sulph.  iehthyolat 1  drachm,  1  scruple 

Aq.  dest 1  drachm,  1  scruple 

Adeps  benzoat i^  ounce 

Adeps  lanae    6  drachms 

M.     Sig. :     Apply  three  times  a  day. 


1 

5 

25 

10 

10 


Ebtsipelas  and  Cellulitis. 

R  Magnesia    sulphate    2  drachms 

Aquse     16  ounces 

M.     Sig.:     Apply  as  a  lotion. 


8|0 
50010 


BUBNS. 


R  Picric  acid  ointment,  1  per  cent. 

Sig.:      Apply  thickly  and  cover  with  strips  of  oiled  silk,  then   steril  gauze 
and   bandage. 


EcZEilA. 
Cooling  lotions: — 

R  Pulv.  calamini  %  drachm 

Pulv.   zinci  ox %  drachm 

Glycerin!     15  grains 

Aq.  calcis   1  ounce 

M.     Sig.:     Apply  three  times  a  day. 


908 


MISCELLANEOUS. 


Or:— 

IJ  Phenol   20  drops 

Zinc,  oxid 3  drachms 

Calamine 2  drachms 

Glycerini .  4  drachms 

Liq.  plumbi  subacet.  dil 1  ounce 

Lime-water   q.  s.  ad  6  ounces 

M.     Sig. :     Apply  three  times  a  day. 

To  stop  itching: — 

IJ  Zinc  oxide    2  drachms 

Amylum    2  drachms 

Naphthalan    1  ounce 

M.     Sig.:     Apply  at  night. 

Or  Unna's  Soft  Zinc  Paste: — 

a.  01.  lini, 
Aq.  calcis, 
Zinci  ex., 
Cretse    of  each,  equal  parts. 

M.     Sig. :     Apply  at  night. 


gtts 


q.  s. 


20 

12 

8 

16 

30 
ad  180 


30 


UbTICAEIA — ^HlVES. 

To   stop   itching: — 

IJ  Resorein, 
Menthol, 

Phenol aa  15  grains 

Alcohol    7  ounces 

M.     Sig.:     Apply  with  cotton. 


aa  110 
200  0 


Scabies. 


IJ  Balsam  Peru 1  drachm 

Sulphur %  drachm 

Betanaphthol   10  grains 

Petrolatum 1  ounce 

M.     Sig.:     Apply  on  affected  areas.     Repeat  three  successive  nights. 


Hypodermic  Medication. 

When  immediate  relief  is  required,  hypodermic  medication  should  be 
given.  The  rapid  action  of  hypodermic  medication  is  best  shown  in  giving 
a  dose  of  apomorphia  hypodermically  for  the  relief  of  spasmodic  croup. 


CHAPTER  XI. 

Remedies  Most  Frequently  Administered: 

For  hypodermic  use  the  dose  should  be  half  that  used  by  the  mouth. 
For  use  hy  rectum  the  dose  should  be  twice  that  used  by  the  mouth. 

Dose  for  Children. — Dr.  Young's  rule :    Add  12  to  the  age,  and  divide 
the  age  by  the  result. 

Example. — For  a  child  2  years  old,  ^^^  =  ^.      The  dose  should  be 
^/t  that  for  an  adult. 

In  giving  powerful  medicines  and  opium  still  smaller  doses  must  be 
used  for  children. 

TABLE  OF  DOSES. 

Owing  to  the  toxic  effect,  drugs  marked  "*"  must  be  given  with  greater  caution. 


Remedies. 


*Acid,    benzoic 

boric    

camphoric   (to  check  night-sweats)    .  .  . 

gallic  

gallic   (in  albuminuria)    

hydrobromie,    diluted    

hydrochloric,    diluted    

*hydrocyanic,   diluted    

nitric,    diluted     

nitrohydrochloric,    diluted . 

phosphoric,   diluted    

salicylic     

sulphuric,    aromatic     

sulphuric,    diluted    

sulphurous   

tannic    

*Aconitina    (white  crystals)    

Aloes     

Aloinum    

Ammonii  benzoas   

bromidum 

carbonas     

chloridum  

lodidum    

valerianas 

*Amyl  nitris    (inhaled  or  internally)    

Antimonii  et  potassii  tartras   (diaphoretic) 

et  potassii  tartras    (emetic)    

oxysulphuret    

Antipyrin     

Apomorphine  hydrochloride   

Argenti   nitras    

*Arsenii  iodidum   

*bromidum     


Fob  Child 
Three  Yeaes  Old. 


1  to  3  grains. 

1  to  2  grains. 
3  to  6  grains. 

2  to  5  grains. 
2  to  12  grains. 
2  to  12  grains. 
1  to  4  grains. 
1  drop. 

1  to  4  drops. 
1  to  4  drops. 
1  to  6  drops. 
1  to  4  drops. 
1  to  3  drops. 

1  to  6  drops. 

6  to   12  drops. 
0.4  to  2  drops. 
Moo  to  1^00  grain. 
0.4  to  1  grain. 
0.025  to  0.6  grain. 

2  to  4  grains. 

1  to  6  grains. 
0.6  to  2  grains. 

2  to   6   grains. 
0.4  to  3  grains. 
0.4  to  3  grains, 
0.4  to  1  drop. 
0.01  to  0.02  grain. 
0.2  to  0.4  grain. 
0.1   to   0.4  grain. 
0.4  to  3  grains. 
Vio  to  %  grain. 
0.035   to   0.1   grain. 
0.003    to    0.02    grain. 
0.003  to  0.012   grain. 

(909) 


910. 


MISCELLANEOUS. 


Remedies. 


*Atropinse  sulphas   

*Auri  et  sodii  cliloridum   

Bismuthi    subnitras     

salieylas    

*Bi-omof ormum   ( in  whooping-cough,  etc. )    

Caffeine     

Calcii   chloz'idum   hydratum 

Calcii    lacto-phosphas    

Camphora     

monobromata     • 

Cerii   oxalas    

Chinoidinum    

Chloral    

Chloralamidum    (hypnotic)    

Chloroformum     

Chrysarobinum    (eczema)     

Cinchonidina,   and   its   salts    

Cocaina   (locally,  14  psr  cent,  solution),  internally 

Codeina     - 

*Colchicine     

Confectio  sennse 
*Creolin   (locally,  ,i^|  to  2  per  cent,  solution)   internally.. 

Creosotum    

Oroton-chloral     

Cupri  acetas    

sulphas     ( emetic )     

*Digitalinuni     

*Digitalis     

*Duboisina,  and  salts   

*Elaterinum   (U.  S.  P.,  1880)    

Emetina,  and  salts    (emetic)    

Ergota     

Ergotinum     

*Eserina,   and  its   salts    

Ethyl  chloride    (local  anaesthetic)    

Fel  bovis  purificatum   

Ferri    arsenas     

bromidum     

carbonas    saccharatus    

et  ammonii  citras    

et  ammonii  tartras   

et   potassii   tartras    

et  strychninse  citras    

hypophosphis     

iodidum    saccharatum     

lactas     

pyrophosphas 

subcarbonas   

Ferri   sulphas    

sulphas  exsiccatus    

valerianas     

Ferrum  dialys  

reductum    

Gaultheria,   oil  of    

Guaiacol    (constituent  of  creosote)    

Guaiacol  carbonas  vel  benzoas   

Homatropinse  hydrobroraidum  (mydriatic,  locally,  0.2 
per  cent,  to  4  per  cent. )    


Fob  Child 
Three  Years  Old. 


0.0015  to  0.006  grain. 
0.006   to    0.025   grain. 
1  to  12  grains. 
1   to  4  grains. 
1  to  2  drops. 
0.2  to  1  grain. 
1   to  4  grains. 
1  to  2  grains. 
0.6  to  2  grains. 
0.4   to   1   grain. 
0.2    to   2   grains. 
0.6  to  6  grains. 
0.6  to  4  grains. 
3  to  12  grains. 
0.2  to  6  drops. 
0.035  to  0.6  grain. 
1  to  6  grains. 
0.012   to   0.1   grain. 
%  to  14  grain. 
0.002  to  0.004  grain. 
12   to   24  grains. 
0.1  to  1  drop. 
0.1    drop,    gradually    in- 
creased. 
0.2  to  1  grain. 
0.025  to  0.1  grain. 
0.012   to   0.05   grain. 
0.003  to  0.006  grain. 
0.025   to  0.4  grain. 
0.0015    to   0.0033   grain. 
0.0035   to  0.016  grain. 
0.025   to  0.05  grain. 
3  to  12  grains. 
0.4  to   1.6  grain. 
0.003  to  0.01  grain. 

1  to  2  grains. 
0.01    to   0.035    grain. 
0.2   to    1   grain. 
0.4  to  3  grains. 
1  to  2  grains. 

1  to  3  grains. 

2  to  6  grains. 
0.2  to  1  grain. 
1  to  2  grains. 
0.4  to  1  grain. 
0.2  to  0.6  grain. 
0.2  to  1  grain. 

1  to  6  grains. 

3  to  5  grains. 

2  to  5  grains. 
2  to  3  grains. 
2  to  3  grains. 
2  to  3  grains. 
0.6  to  2  grains. 
1  to  2  grains. 
0.065  to  2  grains. 


TABLE  OF  DOSES. 


911 


Eemedies. 


locally,    (25 


Commencing     doses 

to  be 
increased    cautiously 


*Hydrargyri  chloridum  conosivum   

*chloridum  mite  

*Hydrargyri   iodidum   rubrum    

iodidum  vir 

subsulphas  flava  (as  emetic)    

HydrargjTum  cum  creta    

Hydrastine     

Hydrogenii   dioxidum    (10-volume  solution) 

to  100  per  cent.),  antiseptic 

*Hyoscin8e  hydrobromas 

*Hyoscyaminse  sulphas   

Ichthyol    (locally,   10  to  50  per  cent.),  internally 

Infusum  digitalis   

lodoformum     

lodol    

lodum    

Ipecacuanha    (expectorant)     

Ipecacuanha    (emetic) 

Jalapa     

Liq.   amnionii   acetatis    

acidi   arseniosi    

arsenii    bromidi     

arseni  et  hydrargyri  iodidi 

potassii    arsenitis     

sodii    arseniatis    

ferri    chloridi .' .' 

ferri    dialys 

potassii    citratis     

Lithii    benzoas    

bromidum 

carbonas     

citras    

salicylas 

Lupulinum     

Magnesii    carbonas     

citras,   gran 

sulphas     

Mangani   oxidum   niger    

Methylene  blue  with  powdered  nutmeg  (malarial  fevers 
Mistura    chloroform!     

ferri  et  ammonii  acetatis    

glycj'rrhizae    composita     

potassii    citras    

rhei    et    sodse    

Morphin  and  its   salts    *.  . 

Morrhuol   (derivative  of  codliver  oil)    

Moschus   

Naphthol     

*jSritroglycerinum    (trinitrin),  %  per  cent,  solution   .... 

Oleoresina  aspidii    (filix  mas) 

Opium    ( 14   per   cent,   morphine)     

PhenocoU    hydrochloride     

*Phosphorus     

*Pilocarpiua,    and   salts    (cautiously)     

Piperazin     

Plumbi    acetas    

Potassii    acetas     

bicarbonas 

Potassii    bromidum     


Foe  Child 
Tu  UKK  Yeabs  Old. 


0.003  to  0.002  grain. 
0.012  to  2  grains. 
0.004   to   0.02   grain. 
0.035   to   0.2   grain. 
0.4  to  1  grain. 
0.6  to   1.6  grains. 
0.6  to   1  grain. 


0.001  to  0.0035  grain. 
0.001  to  0.003  grain. 
U.G  to   1  grain. 
15  to  30   drops. 
0.2  to  1  grain. 
0.035   to  0.1   grain. 
0.02  to   0.05   grain. 
0.035    to    0.2    grain. 
3  to  6  grains. 
3  to  6  grains. 
15  to  30  drops. 


0.2  to   1   drop. 


2  to  5  drops. 

2  to  6  drops. 
15  to  30  drops. 
1  to  4  grains. 

1  to  4  grains. 
0.4  to  2  grains. 
1   to   4  grains. 
1   to   6  grains. 

1  to   6  grains. 

3  to    12    grains. 
5   to  20   grains. 

2  to   6  grains. 
0.2   to    1   gi'ain, 
0.2   to    1   grain, 
1  to  5  drops. 

5  to   15  drops. 
5  to   15   drops. 
5   to   15  drops. 
10  to  30  drops. 
Hoo   to  1^5  grain. 
10  to  30  drops. 
0.4  to  3  grains. 
0.4  to  1  grain. 
1  to  2  drops. 
1   to  3  gi'ains. 
0.025   to   0.4  grain. 
1.6  to  3  grains. 
0.0015  to  0.004  grain. 
0.003  to  0.001  grain. 

3  grains    (daily). 
0.1  to  0.6  grain. 

3  to  12  grains. 
1.6   to   12   grains. 
1.6   to   12   grains. 


912 


MISCELLANEOUS. 


Remedies. 


Potassii  bitartras     

chloras     

cyanidum     

iodidum 

.nitras     

permanganas     

Pulvis   antimopialis    

glycyrrhizse    compositus    

ipeeacuanhse    et    opii     

jalapae    compositus     

rhei   compositus    

Kesina    copaibse    

guaiaci 

jalapae     

podophylli     

seammonii     

Resorcin     

Rheum 

Saccharine    ( substitute  for   sugar )    

Salicinum     

Salipyrin    (antipyretic,    antineuralgic)     .... 

Salol     , 

Salophen    ( antipyretic,   antirheumatic )     .  .  .  , 

Santoninum     

Senna     " 

*Sodii   arsenas    

benzoas     

boras    ( in   epilepsy )     , 

bromidum     

chloras    

hyposulphis     

iodidum    

phosphas     

salicylas     

*Spartein3e  sulphas    (cardiant  and  diuretic) 
Spiritus   setheris   nitrosi    

setheris   compositus    

ammonise   aromaticus    

camphorse     

chloroformi     

Strontii  lactas  vel  bromidum  vel  iodidum 

*Strychnina,    and    salts    

Sulphonal   (best  in  hot  mint- water)    

Sulphur     

Syr.    ferri    bromidi    

ferri   iodidi 

scillse    compositus     

senegse     

sennse    

Terebene     - 

Terpin  hydrate    (tonic  expectorant)    

Theobrominse   et   sodii   salicylas    (diuretic) 

Thymol 

*Tinctura    aconiti    

aloes    

asafoetidse     

belladonnse     

cannabis    indicse     

capaici    


Foe  Child 
Three  Yeabs  Old. 


0.2    to   0.4   grain. 
1.6   to   6   grains. 
0.01   to   0.025  grain. 
0.4   to   6   grains. 
0.4  to  3  grains. 
0.1    to    1    grain. 
0.2  to  0.6  grain. 
6  to  12  grains. 

1  to   3  grains. 

2  to  5  grains. 

1   to    12    grains. 
0.4  to  2  grains. 
1  to  4  grains. 
0.4   to    1   grain. 
0.016  to  0.1   grain. 
0.4  to  2  grains. 
0.4  to    1    grain. 
0.4  to  6  grains. 
0.1  to  1  grain. 
1  to  6  grains. 
1.6  to  3  grains. 
0.4  to  2  grains. 

3  to  4  grains. 
0.05   to   1   grain. 
1.6  to  36  grainns. 
0.003   to  0.02   grain. 
1   to   3   grains. 

1   to   6  grains. 

1   to   6  grains. 

0.4  to  1  grain. 

1  to  4  grains. 

0.4  to  6  grains. 

0.4  to  24  grains. 

1  to   6  grains. 

0.012    to   0.8   grain. 

3  to  24  drops. 

3  to  24  drops. 

3  to  12  drops. 

1  to  6  drops. 

3  to  12  drops. 

3  to   12  grains. 

0.003    to    0.016    grain. 

1  to  4  grains. 

1  to  0  grains. 

1  to  12  drops. 

1  to  6  drops. 

1  to  6  drops. 

5  to  15  drops. 
10   to   20    drops. 
1   to   3   grains. 
0.4  to  1  grain. 

1  to  6  grains. 
0.2  to   1  grain. 
1  to  2   drops. 
3  to   12  drops. 

6  to   12  drops. 
0.4  to  3  drops. 
1  to  4  drops. 
1.6  to  3  drops. 


TABLE  OF  DOSES. 


913 


Remedies. 


Tinotura  cimiclfugae     

einchonae    composita     , 

colchici    seminis     

conii     

•digitalis     

feiri    chloridi     

gelscmii     

giiaiaci   ammoniata    

hydrastis 

hyoscyami     

iodi    compositus     

kino     

musk     

nucis   vomicae    

*opii    , 

opii    camphorata    

stramonii     

strophanthi    (eardiant  and  diuretic)     .... 

Valerianae    ammoniata     

veratri    A'iridis 

*Trional     (hypnotic)      

Trituratio   elaterini    (10   per  cent.)     

Vinum  antimonii  (expectorant  and  alterative 
(emetici)      

colchici     

ergotse     

ipecacuanha;   ( expectorant)      

(emetic)      

opii    

Zinci    acetas    

bromidum     

iodidum    

oxidum     

phosphidum     .  .• 

sulphas     ( emetic )     

valerianas 


Fob  Child 
'J'liKKE  Yeabs  Old. 


6  to  12  drops. 
li  to  24  drops. 
1  to  4  drops. 

1  to  6  drops. 
O.G  to  3  drops. 

2  to  6  drops. 
0.4  to  3  drops, 
t)  to  12  drops. 
G  to  24  drops. 
1   to  6  drops. 
1.4   to   3   drops. 

3  to  24  drops. 
3  to  12  drops. 
1   to  3   drops. 
0.4  to  3  drops. 
1   to  48  drops. 

1  to  3  drops. 
0.2  to  2  drops. 

2  to  24  drops. 
0.6    to    2    drops. 

3  to  12  grains. 
0.025  to  0.2  grain. 
1   to   5   drops. 

6  to   15   drops. 
1  to  3  drops. 
1  to  5  drops. 
1  to  3  drops. 
5   to   15   drops. 
1  to  2  drops. 
0.1    to    0.4   grain. 
0.1  to  1  grain. 
0.1   to  0.6   grain. 
0.2  to   1  grain. 
0.02   to  0.035   grain. 
3  to  6  grains. 
0.1   to  1  grain. 


68 


INDEX. 


Abdomen,    72 
in  ascites,  358 
in  cretinism,  719 
in  dislocation  of  the  hip,  863 
in   Henoch's   purpura,    708 
in   intussusception,   285 
in  peritonitis,  354 
in    pseudo-Ieuksemic   ansemia,    695 
tapping  the,  360 
Abdominal  band,  21 

in  gastroptosis,   234 
in  pertussis,   458 
Abnormal   growths,    842 
Abnormalities,  congenital,  57 

of  air  passages,  60 
Abortive   pneumonia,   462 
Abscess,  complicating  Pott's  disease,  851 
complicating   vaccination,    644 
in   angina  Ludovici,   216 
in    perinephritis,    374,    375 
in  pyelitis,  377 
of   brain,    804 
of  cervical  region,   852 
of   inguinal  region,   852 
of  liver,  347 
of  loin,   852 
of  spine,  852 
of   thoracic   region,   852 
alveolar,  215 
cerebral,  804 
hepatic,  347 

caused  by  worms,   291 
isclhio-rectal,    295 
peritonsillar,   406,   522 

resembling  diphtheria,  522 
retro-oesophageal,   217 
retro-pharyngeal,  415 

complicating  scarlet , fever,  415 
subphrenic,   351 
Abscesses,   in  erysipelas,   659 
in  typhoid,  654 
multiple,     complicating    cerebro-spinal 

meningitis,  784 
renal,   of  urinary   passages,   377 
AcetonjEmia,   380 
Acetonuria,   380 

in  diabetes  mellitus,   394 
Acid,  carbolic,  as  disinfectant,   894 
hydrochloric,    in   gastric    contents,    66, 

875 
lactic,  in  gastric  contents,  66,  875 
Acidaemia,  384 
Acidosis,    132,   235,   384 
Acute  milk  infection,  256 


Addison's   disease,    732 
Adenitis,   acute,    712 

chronic,   713 

retro-pharyngeal   lymph-,   416 

tubercular,  714 
Adenoid  vegetations,  411 

a  point  of  entrance  of  tubercle  bacilli, 
485 

causing  deafness,  408 

causing   enuresis,    389 

congenital,  59 

face,  412 

method  of  examining  for,   412,   413 

operation,   414 

haemorrhage  after,  415 
Adherent   prepuce,   363 
Adhesia   linguae,   59 
Adhesions,   in   pleurisy,   436 

in   chronic   empyema,   443 
Administration  of  drugs,   895 
Adrenal  glands,  diseases  of,  732 
Adulteration    of    milk,     119     (see    also 

Milk    Preservatives,    121) 
Ague    (see  also  Malarial  Fever),  662 
Air  passages,   abnormalities   of,   60 
Airing  out  of  doors,  21 
Alalia  idiopathica,   806 
Albumin,    concentrated    preparations    of, 
194 

in  milk,  effect  of  heat  on,  153 

in  urine,  878 
test  for,  881 

milk,    140 

transformation    of,    by    gastric    juice, 
67 

water,   868 
Albuminoids  in   cows'   milk,   138 

in  human  milk,  76 
Albuminuria,  878 

in  malarial  fever,   670 

in  measles,  588 

in  nephritis,  371,  879 

lordotic,  381 

orthostatic,   381 

resulting  from  exercise,  24 

transient,  in  scarlet  fever,   614 
Albimioscope,  872 
Alcohol,   content  in   liquid  foods,   177 

internally,   203 
abuse  of,  245 
Almond  milk,   868 
Alveolar  abscess,  215 

arch,    in    adenoid    vegetations,    411 
Amaurotic  family  idiocy,  810 
Amoebic  dysentery,  251 

(915) 


916 


INDEX. 


Amyloid  degeneration,  879 

of  the  liver,  349 
Amylopsin  ferment  t€st,  226 
Anapliylactic    shock,    518 
Anaphylaxis,    423,    517,   589 
Anaemia,    69 1 

associated   with   masturbation,    754 

acquired,   691 

congenital,   691 

following  diphtheria,   525 

in  Addison's  disease,  732 

infantum    pseudo-leukfemica,    694 

pernicious,    692 

pretubercular,  493 

pseudo-leukaemic,    694 

secondary,  692 

splenic,  691 
Anaemic  murmurs,  331 
Anaesthesia,   890 

intraspinal,   892 

local,  892 

partial,   in   multiple   neuritis,   752 
Anaesthetic,    in    adenoid    operation,    414 
in   empyema,   442 
in  tonsillotomy,   409 

chloroform,  890 

ether,   891 

ethyl  chloride,  891 

nitrous  oxide,  890 
Analyses   of   cows'   milk,    114,    115 

of  woman's  milk,  78,  80,  83 
Anaphylaxis,   517 
Anasarca,  general,  in  leukaemia,   694 

in  nephritis  complicating  scarlet  fever, 
626 

in   post-scarlatinal    nephritis,    617 

in   tuberculosis   of  the   lung,   481 
Angeioma,  57 
Angina  Ludovici,  216 

pseudo-membranosa    in    scarlet    fever. 
608 
scarlatina  membranosa,   610 

tonsillaris,   403 
Ani,  prolapsus,  296 
Ankle,  oedema  of,  in  chlorosis,  696 
Ankle-joint,  diseases  of,  865 

in   rachitis,    311 
Anorexia,   in   acut€   tuberculosis,    493 

in  measles,  585 

in  meningitis,   787 

in  rheumatism,  699 

in   rubella,   578 
Antibacterial  action  of  the  blood,  688 
Anticolic  nipple,   151 
Antimeningitis   serum,   791 
Antipyretics,  in  broncho-pneumonia,   433 

in  cerebral  pneumonia,  474 

in  influenza,  450 

in  scarlet  fever,  619 

in  typhoid  fever,   655 
Antiscorbutic  diet,  145 
Antistreptococcus    serum,    in    erysipelas, 

659,  661 
Antistreptococcus  serum,  in  scarlet  fever, 
628 


Antistreptococcus    serum,    in    tubercular 

peritonitis,  358 
Antitoxin   anaphylaxis,    517 
diphtheria,   534 
in  omphalitis,  35 
eliminated  by  woman's  milk,  82 
in  meningitis,  792 
in  tetanus,   759 
in  typhoid,   655 
rashes,  515 

streptococcus,  in  erysipelas,  659,  661 
in  sca.rlet  fever,  626 
Anus,  absence  of,  63 
atresia  of,   63 

condylomata  of,   in   syphilis,   676 
congenital  narrowing  of,   63 
iissure  of,  294 
Aorta,  331 

area  of  murmur,  331 
Aortic  bruit,  332 

cusps   in   diastolic  murmur,   332 
from  aneurism,  332 
systolic   murmur,    332 
valves,    in    diastolic    murmurs,    331 
Aphasia,  complicating  cerebral  paralysis, 
798 
complicating   diphtheria,    523 
complicating  pertussis,   451 
complicating   typhoid,    654 
Aphonia,  due  to  paralysis,  4 
in  hereditary  ataxy,  767 
spastica,  intubation  in,   554 
Aphthae,  Bednars,  208 
Appendicitis,   278 

diflferential    diagnosis,    from    abscess 
of  ovary,  281 
from  colic,  281 
from  hip-joint  disease,  281 
from  intussusception,  281 
treatment,  281 

operation,   interval,  282 
catarrhal,  281 

false  (see  also  Pseudo-appendicitis), 282 
gangrenous,  279 
helminthic,  279 
ulcerative,   279 
Appendix,  vermiform,   location  of,   73 
Appetite,   in   gastroptosis,   232 
abnormal,  231 
loss  of,  229 

due  to  catarrh,  394 
Arm  in  birth  palsy,  44 
Arthritis,   866 

following   empyema,   866 
following  measles,   866 
following  scarlet  fever,  866 
following  traumatism,  866 
Arthus  j)henomenon,  518 
Articular  rheumatism,   700 
Artificial    feeding     (see    also    Bottle    or 

Hand  Feeding),   150 
Arrhythmia  in  myocarditis,   343 
Ascaris  lumbricoides,  290 
Ascites,  358 

treatment,   359 


INDEX. 


917 


Ascites,      troatincnt,      tapping     the     ab- 
domen, 'MiO 
due  to  peritonitis,  359 
Asphyxia,   during  intubation,   553 
in  diphtheria,  525 
in   pertussis,  457 
in   retro-pharyngeal  abscess,   416 
neonatorum,  45 
Aspiration    (see  Lumbar   Puncture), 
in  ascites,  560 
in  encephalocele,  777 
in  hydrocephalus,  775 
in      nephritis,      complicating      scarlet 

fever,   621 
of  chest  in  pleurisy  with  effusion,  438 
of  pericardium,  341 
Asthma,  bronchial,  428 
dyspeptic,  236 
thymic,  713 
Ataxia,  hereditary,  766 
Atelectasis  pulmonum,  complicating  per- 
tussis, 457 
diflferentiated   from   pneumonia,   472 
in  bronchitis,  426 
in  diphtheria,  544 
in  premature  infants,  33 
Athetosis  in  cerebral  paralysis,  797 
Atomizer,  392 
oil,  418 
steam,  419 
Atony,  general,  in  gastroplosis,  232 

of  intestine,  '299 
Atresia  ani,  63 
Atrophy,  infantile,  321 
urine  in,  878 
in  acute  myelitis,  764 
in  multiple  neuritis,  752 
in  pseudohypertrophic  paralysis,  802 
Aura,  of  epilepsy,  761 

of  hysteria,  749 
Auscultation,   in   asthma,   423 
in  bronchitis,   426 
acute  catarrhal,  423 
capillary,  423 
in  emphysema,  423 
in   fluid  or  air  in  pleural   sac,   423 
in  pleurisy,  423 
subacute,   423 
in  pneumonia,  423 
in   tuberculosis,  424 
of  anterior  fontanel,   733 
Auto-intoxication,    285 

Babcock's  milk  test,   133 
Babinski  reflex,  737,  786 

in   hereditary   ataxia,   767 

in    tubercular   meningitis,   782 
Bacillary  diphtheria  of  the  colon,  252 
Bacillus,  of   diphtheria,   502 

of  Eberth,  in  typhoid,  464 

of  influenza,  396 

of  Pfeiflfer,  395 
Klebs-Loeffler,  502,  503 

stain   for,   889 
pyocyaneus,  in  bronchitis,  425 


Bacillus,  tubercle,  486 

stain  for,   in  ^^putum,  888 
typhoid,  646 

Vincent's,   in    ulcero-membranoua   ton- 
sillitis, 405 
Back-knee  in  rachitis,  320 
Backwardness,  3 

differentiated   from   idiocy,   807 
in  speaking,  806 
Bacteria,   action   of  gastric  juice  on,   fi^ 
action  of  saliva  on,  66 
in  bronchitis,  425 
in  broncho-pneumonia,  430 
in  cows'  milk,  77 
in  cystitis,  387 
in  empyema,   387 
in  erysipelas,   658 
in  follicular  tonsillitis,  405 
in  measles,   584 
in   perinephritis,   374 
in  pertussis,   455 
in  vaginitis,   366 
in  woman's  milk,  76 
of  intestines,  243 
Bacterial  vaccines,  450 
Bacteriological  memoranda,  888 
Baginsky  tonsillotome,   409 
Baldness  of  occiput,  in  rickets,  311 

in  scurvy,  306 
Baud,  abdominal,  21 
in  gastroptosis,  234 
in  pertussis,  458 
Banti's  disease,  691 
Barlow's  disease,   301 
Basedow's   disease    (see   also  Exophthal- 
mic  Goiter),   731 
Basham's  mixture,  627 
Basilar  meningitis  (see  also  Meningitis), 

779 
Bath,  at  birth,  18 

in  diphtheria,  533 
in  rheumatism,  703 
in  syphilis,  682 
in  typhoid,  655,  689 
temperature  of,  19 
thermometer,  19 
bichloride,  in  syphilis,  682 
hot  air,  621 

hot     and     cold,     in     asphyxia     neona- 
torum, 47 
hot,  as  a  diaphoretic,  620 
oatmeal,   19 

spray,  in  hysteria,  751 
sulphur,   in   rheumatism,   703 
tub,  in  typhoid,  655 
Bednar's   aphthce,   208 
Bed-wetting,    a    symptom    of    phimosis, 
363 
caused  bv  presence  of  adenoids,  412 
Beef- juice,  '868 
Bell's  paralysis,  802 
Benger's   food,   191 

Beriberi  caused  by  lack  of  vitamines,  144 
Bicarbonate  of  soda  solution,   143 
Bifid  tongue,  214 


918 


INDEX. 


Bifid  uvula,  215 

Bile,   346 

Bile-duets,  congenital  obliteration  of,  37 

Bilious  attack   (see  also  Dyspepsia),  219 

Birth  palsv,  43 

Bladder,   3''78 

extroversion  of,   378 
location  of,  378 
proper  training  of,  23 
stone  in,   386 
washing,   386,   387 
Bleeders    (see  also  Hgemophilia),  709 
Blepharitis,  824 

Blindness   following  meningitis,   791 
Blisters    (see  also  Burns),  839 
Blood,   683 

antibacterial  action  of,  688 
at  birth,   683 

circulation    of,    during    foetal     period, 
325 
in  early   life,   326 
crisis,  in  pneumonia,  467 
effect  of  antitoxin  on,   536 
erythroblasts,   684 
examination  of,  667 

to  prepare  specimen,  651 
in   ansgmia,    691 
in  bronchitis,  685 
in  chlorosis,  696 
in  diphtheria,  508,  523 
in  fcA'er,  689 

in  gastro-intestinal  diseases,   686 
in  hereditary   syphilis,   685 
in  infectious  diseases,  687 
in  malarial  fever,  662 
in  meningitis,  787 
in  multiple   neuritis,   752 
in  nephritis,  371 
in  nervous   diseases,   686 
in  perinephritis,  375 
in  pneumonia,  467,  685 
in  rachitis,   686 
in  scarlet  fever,  602,  622 
in  skin  diseases,  686 
■  in  typhoid,   651 
in  Winckel's  disease,  41 
inclusion  bodies  in,  647 
letting,   local    ( see   also   Venesection ) , 

897     . 
pathological  conditions  in  disease,  687 
reaction  of   pus,   686 
serum  treatment  in  scarlet  fever,   628 
test  for,  in  urine,  886 
Blood-vessels    (see   Thrombosis), 
dilatation   of,   in   angeioma,   57 
in   hsemophilia,    709 
in  spinal   paralysis,   768 
in   syphilis,  674 
Bloody  urine   (see  also  Hsematuria),  382 
in   diphtheria,   513 
in  septic  diphtheria,  524 
Blue  baby,  333 

Boil    (see  also  Furuncle),   835 
Bone-marrow,  in  leukaemia,  693 
Bones    (see  Fractures;  also  Joints). 


Bones,  in  hydrocephalus,  776 
in  rachitis,  310 
in   syphilis,    677 
in  tuberculosis,  677 
Borborygmus,  273,  293 
Bothriocephalus  latus,  289 
Bottle-brush,  151,  152 
Bottle-feeding,   150 
formulae,   160 
rules  for,   158 
utensils  required  for,   150 
Bottles, 'feeding,   150,   151 
Bovine  tuberculosis,  485,  493 
Bowel  movements    (see  Stools). 
Bowels,   inflation   of,   in   intussusception, 
288 
obstruction   of    (see   also    Intussuscep- 
tion), 284 
proper  training  of,  23 
Bow-legs,  3 

in  rachitis,  314,  320 
Bradycardia,  330 
in  diphtheria,  514 
in  myocarditis,  343 
Brain,  778 

abscess  of,   804 
concussion  of,  811 

engorgement     of,     in     cerebral     pneu- 
monia,  475 
in  tubercular   meningitis,   780 
water  on,  774 
Breast-feeding,   84 

dangers  of  suffocation  during,  87 
disturbances  during,  88 
schedule  for,  84 
suggestions  for,  87 
Breast-milk    (see   also   Milk,   Woman's), 

74 
Breast-pump,  80,  93,  94 
Breasts,    massage    of,    during    lactation, 
94 
pear-shaped,  best  adapted  for  nursing, 
106 
Breath,   in  alveolar  abscess,  216 
in  lithsemia,  709 
in  pulmonary  gangrene,  435 
in  stomatitis  gangrsenosa,  211 
Breathing    (see   also   Respirations),    424 
Cheyne-Stokes,  in  meningitis,   783 

in  tubercular  pneumonia,  478 
in  bronchial  asthma,  428 
in  diphtheria,  426 
in  dry  pleurisy,  437 
in  empyema,  440 
in  pleurisy  with  effusion,  438 
in  tubercvilous  pneumonia,  478 
labored,    in    retro-pharyngeal    abscess, 
416 
Breck's   feeder  for  premature  babies,   31 
Bright's    disease     (see    also    Nephritis), 
370 
urine  in,   879 
Bromide,  administration  of,  per  rectum, 
896 
of  ethyl,  as  an  anaesthetic,  891 


INDEX. 


919 


Bronehi,  diseases  of,  423 

in  bronchitis,  425 

in  tubort'iilous  pneumonia,   380 
Bronchial    asthma,   428 
treatment,   429 

catarrh,  425 

glands,  enlarged,  428 
Bronchitis,   425 

treatment,  427 

complicating   typhoid,    650 
Broncho-pneumonia,   429 

complicating  diphtheria,  522 

complicating  measles,   592 

complicating  pertussis,  457 

complicating  variola,   642 

differential  diagnosis  from  atelectasis, 
433 

fibrous,    433 

physical  examination   in,  432 

pneumonia  jacket,  431 

predisposing  causes,   430 

tuberculous,  498 
Broths,  870 
Brudzinski's    neck    sign    in    meningitis, 

786 
Buhl's  disease,  41 
Bulgarian  bacillus,   119,  265 

milk,  174 
Bulimia,  231 

a  symptom  of  hysteria,  231 
Burns,    839 
Buttermilk  feeding,  173 

how  to  prepare,   174 
Butyric-acid  test  for  syphilis,  673 
Byrd  method  of  resuscitation,  46 

Caecum,  73 

Caffeine,  effect  of,  202 

"Caking"  of  breast,  94 

Calcium  salts,   141 

Calculi,  giving  rise  to  bloody  urine,  382 

in  bladder,  386 

urethral,  386 

vesical,   386 
Calmette  tuberculine  test,  497 
Calorie  method  of  feeding,  158 
Cancrum     oris      (see     also      Stomatitis 

Gangrsenosa ) ,   210 
Cane  sugar,   137 
Cantharidal    collodion,    897 
Capillaries  in  hferaophilia,  710 

in  malarial   fever,   666 
Caput  succedaneum,   62 
Carbohydrates,   135 
Carbolic  acid  as  a  disinfectant,  909 
Carcinoma,   845 
Cardiac  diseases,  classification  of,   330 

paralysis,  527 

in  dysentery,  253 
Carious  "teeth,   in   rickets,   312,   313 

possible  point  of  entrance  of  tubercle 
bacilli,  485 
Casein,   140 

in  cows'  milk,  77 

in  woman's  milk,  76,  86 


Casein,  in  milk,  140 

Casts  in  urine,  in  nephritis,  372 

Catarrh,  acute  nasal,  391 

treatment,  392 
Catarrh,   bronchial,  425  ^ 

duodenal,  276 
Catarrh,  follicular,  404 

gastric,   394 

in  syphilis,   075 

naso-pharyngeal,    394 

with  adenoid  growths,  391 
Catarrhal   conjunctivitis,   819 

croup,   417 

epidemic  fever,   395 

jaundice,    228 

nephritis,  614 

pneumonia,   429 

proctitis,  294 
Cavities  of  the  lung,  477,  479 
Cellulitis,   complicating  vaccination,   644 

of  neck,  in  scarlet  fever,  613 
Centrifugal  milk-testing  machine,   133 
Cephalhfematoma,  61 

.  spurious,   62 
Cereal  milk,    185 
Cereals,  164 
Cerebellum,  737 

abscess  of,  804 
Cerebral  abscess,  804 

congestion,    in    pneumonia,    475 

hcemorrhage,   in  pertussis,  457 

hernia,   777 

hypersemia,   in   insolation,   246 

paralysis,  795 

pneumonia,   464 

thrombosis,     complicating     diphtheria, 
524 
Cerebrospinal     fluid,     673.       (See     also 
Spinal   fluid.) 

meningitis,    784 
Cerebrum,   737 

Certified  milk  in  New  York  City,  118 
Cestodes,  289 

Chamomile   injections,   274 
Chatillon  weight  scale,  108 
Chemical  examination  of  cows'  milk,  77 
of   gastric   contents,   875 
of  urine,   877 
of  woman's  milk.  78 
Chest,   in  broncho-pneumonia,   592 

in  cerebral  pneumonia,  448 

in  chronic  pericarditis,  342 

in  empyema,  448 

in   pleurisy   with   effusion,  438 

in   rachitis,   312 

in    spasmodic   laryngitis,    418 

strapping  of,   in   dry   pleurisy,   437 
in   pleurisy  with   effusion,   439 
Cheyne-Stokes   respiration,   in  tubercular 
meningitis,   786 
in   tuberculous  pneumonia,  478 
Chicken-pox    (see  also  Varicella),   633 
Childhood,  1 
Chills,   in  diphtheria,  512 

in  orchitis   complicating  mumps,   717 


920 


INDEX. 


Chills,  in  perinephritis,  375 

Chloasma,   832 

Chloral  hydrate  in  convulsions,  741 

Chloransemia,  695 

Chloride  of  lime,  as  a  disinfectant,  894 

Chloroform,  890 

in  control  of  spasms,  741 
Chlorosis,  695 

blood  in,  697 
Chocolate  and  cocoa,  200 

how  to   prepare,   868 
Cholera  infantum,  256 

resembling  typhoid,   652 
Cholelithiasis,   348 
Chorea,  744 

causes,  744 

symptoms,  746 

treatment,  747 
Chrostek's    phenomena,    757 
Circulation,   changes  in,  at  birth,   325 

foetal,  325 
Circumcision,  363 

in  treatment  of  masturbation,   755 

operation  for,  364 

tuberculosis    infection   through,    480 
Cirrhosis  of  the  liver,  350 

splenomegalic,  691 
Cleft  palate,  58 
Clothing,   20 

in  summer,  20 

in  winter,  20 

night,  21 
Clitoridectomy,   in   masturbation,   755 
Cocaine    as    an    intra-spinal    ansesthetic, 

892 
Cocoa,  how  to   prepare,   200,   868 
Coffee,  202 

Cold,   as  an  antipyretic,  434 
in  typhoid,  655 

compresses,  434 

ice   collar,   in   tonsillitis,   403 

pack,  in  chorea,  748 
in  pneumonia,  473 

spray  bath,  in  hysteria,  751 
Colic,  a  symptom  of  worms,  290 

in  breast-fed  babies,  274 

intestinal,  273 
Colicystitis,  385 
Colitis   (see  also  Ileo-colitis ) ,  252 

amffibic,  251,  255 

diphtheritic,  252,  253 

mucous,   in   syphilis,  675 
Collapse,   in   diphtheria,   515 
in  dysentery,  253 

pulmonary      (see     Atelectasis     Pulmo- 
num). 
Colles's  law,  673 
Collodion,  cantharidal,  897 

iodoform,     in     tubercular     meningitis, 
783 

salicylic,  in  mumps,  716 
Colon,   bacillus   in   bronchitis,    426 
perinephritis,   436 

course  of,  73 

dilatation  of,  272 


Colon,  flushing,  in  intestinal  colic,  275 
irrigation  of,   in  diarrhoea,  245 
in  dysentery,  266 
in  typhoid,  655 
Colored  race,   mortality  in,  from  tuber- 
culosis,  491 
Colostrum,   74 
Colostrum,  corpuscles  of,  74 

proteins  in,   104 
Coma,  in  angina  Ludovici,  216 
in    cerebral    pneumonia,    464 
in  influenza,  398 
in  pachymeningitis,  792 
in  scarlet  fever,  625 
in  tubercular  meningitis,   783 
to  relieve,  475 
Combustio    (see  also  Burns),  839 
Complement-deviation    test   in   pertussis, 

455 
Composition,    of   cows'   milk,    114 

of  woman's  milk,   compared  with   dif- 
ferent infant  foods,   193 
Concussion  of  the  brain,   811 
Condensed  milk,  179 

causing  scurvy,  301 
Condylomata,  in  syphilis,  676 
Congenital    (see  also  Foetal)    abnormali- 
ties, 57 
adenoids,   59 
cysts  of  the  kidney,  62 
dislocation  of  the  hip,  880 
heart  lesions,  333 
idiocy,  807 
malformations,  57 

of  the  rectum,   63 
obliteration  of  the  bile-ducts,  37 
sacral   tumor,    62 
stenosis  of  the  larynx,  676 
syphilis,  680,  681 
Congestion  of  the  liver,   347 
Conjunctiva,  infection  of,  820 

inflammation      of,      in      acute      nasal 
catarrh,  391 
Conjunctivitis,   acute  catarrhal,   819 
cleansing  the  eye  in,   819 
diphtheritic,  820 
membranous,   820 
phlyctenular,  826 
Constipation,   266 
causes,  267 

sterilized   milk   feeding,    155 
sugar  feeding,   137 
treatment,  269 
diet,  270 
alternating  with   diarrhoea,   229 
in  chlorosis,   696 
in   cretinism,   719 

to   correct,   in  bottle-fed   infants,    130, 
137 
Convulsions,   739 
treatment,  741 
a  symptom  of  worms,  291 
during  teething  period,  741 
epileptic,  760 
in  auto-intoxication,  285 


INDEX. 


921 


Convulsions,  in  cerebral   |)noumoniii,  404 
in  diphtheria,  515,  523 
in  dysentery,  253 
in   hydrocephalus,   776 
in  influenza,  396 
in   lithaemia,   709 
in  meningitis,  786 
in  pachymeningitis,  794 
in  pertussis,  457 
in  post-scarlatinal  nephritis,  617 
in  scarlet  fever,  605,  606 
in   typhoid,   649 
lumbar   puncture,   741 
Ooprostasis,  299 
Cord,    umbilical,    management   of,    17 

separation   of,    1 
Corpuscles  of  blood,  683 
Coryza,   391 

in  measles,   585 
in  rubella,  578 
in  syphilis,  680 
Cough,   in   acute   tuberculosis,   493 
in  croup,  417 
in  dry  pleurisy,  436 
in  pertussis,  456 
in   pleurisy  with   effusion,   438 
in    tuberculous    pneumonia,    478 
in  variola,  642 
croupy,  417,  512 
night,'  421 
reflex,  422 
spasmodic,   422 
useless,  422 
whooping,  455 
Coughs  of  reflex  origin,  421 
Counter-irritants,   435 
Cows,  breed  of,  best  adapted  for  infant 
feeding,   114,   116 
care  of,  117 

time  and  stage  of  milking,  115 
Ayrshire,   116 
Devon,   115 

Durham  or  shorthorn,   115 
Holstein-Friesian,   116 
Cows'  milk,  albuminoids  in,  138 
care  of,  117 
curds  in,   139 
properties   of,   77 
Coxitis     (see    also    Morbus     Coxarius), 

861 
Cranio-tabes,  a  symptom  in  rickets,  312 
Cranium   (see  Skull). 
Cream,    132,    146 

for  home  modification,   146 
how  to  procure,  147 
condensed,  179 
dipper,   147 
gauge,  134 
mixtures,  148 
CredS's    method    of    preventing    ophthal- 
mia neonatorum,   821 
ointment,   in   scarlet   fever,   631 
in  tubercular  meningitis,  783 
Cretinism,  719 
etiology,  719 


Cretinism,   prognosis   and   course,   730 
symptoms,  719 
treatment,   730 

thyroid   implantation,   731 
Crisis,   in  pneumonia,  466,  407 

blood,   467 
Croup,  catarrhal,  417 
treatment,  418 
emetics,  420 
steam  inhalations,  419 
kettle,  420 
spasmodic,  417 
Croupous,   enteritis,   252 
oesophagitis,  217 
proctitis,  295 
stomatitis,  209 
tonsillitis,  405 
Crusta  lacta,  829 
Cry,  as  diagnostic  aid,   13 
from   earache,    13 
from  hunger,   13 
in  cerebral  disease,  13 
in  croup,   13 
in  marasmus,   13 
in   pneumonia,    13 
in   tubercular   peritonitis,   13 
Cryptorchidism,   365 
Cupping,  dry,   897 

in  bronchial   asthma,  428 
in  dry  pleurisy,  437 
in  hsematuria,   382 
in  influenza,  400 
in   meningitis,    791 
in  paralysis,  774 
in  pneumonia,  lobar,  475 
Curvature  of  the  spine,   855 
Cutaneous  tuberculin  reaction,  496 
Cyanosis,    in   acute   tuberculosis,    493 
in  bronchial   asthma,   428 
in  broncho-pneumonia,   431 
in  diphtheria,  545 
in  hydropericardium,  343 
in  pulmonary  tuberculosis,  481 
of  nails,   in   malarial   fever,   670 
oxygen  in,  371 
Curds,  in  cows'  milk,   139 
Cyclic  vomiting,   235 
Cyclops,  778 

Cyst,  congenital,  of  kidney,  62 
Cystitis,  387 
treatment,  389 

Deafness,  as  a  symptom,  408 
caused  by  adenoids,  412 
following  measles,   595 
following  meningitis,   791 
following  scarlet  fever,  620 
with  hypertrophy  of  tonsils,  408 

Decomposition,   321 

Decubitus,  569 

Deficiency  diseasciS,  298 

Deformities,  congenital,  57 
in   rachitis,  308 

Degeneration,    reaction    of,    737 

Delirium,  in  meningitis,  786 


923 


INDEX. 


Dentition,  5 
before  birth,  7 
delayed,   7 
difficult,  6 

eruption  of  first  teetb,  7 
in   cretinism,   719 
in  rachitis,  5 
of  first  teeth,  7 
of  permanent  teeth,  7 
Depressed  sternum,   61 
Descensus  ventriculi,  232 
D'Espines  sign  in  tuberculosis,   494 
Desquamation,   following  antitoxin  rash, 
519 
in  measles,  588 
in  rubella,  580 
in  scarlet  fever,  604,  607 
in  variola,  640 
Development,   mental,   in   cretinism,    719 
in  idiocy,   807 
of  body,  5 
of  infant,  1 

of  the  various  senses,  2,  3 
Dextrin,   136 
Diabetes  insipidus,  383 
Diabetes   mellitus,   384 
Diacetic  acid  test,  886 
Diacetonuria,   380 

Diagnostic  points  in  auscultation,  423 
breathing,    423 
resonance,   percussion,   423 

vocal,   423 
rhythm,  423 
suggestions,  9 
cry,    13 

eye  aphorisms,   12 
gestures,  13 
pulse-rate,   10 
respiration,   11 
sleep,  14 
temperature,   1 1 
throat,   13 
tongue,   13 
x-ray,   15 
Diaphoretics,   hot-air  bath,   626 
hot  pack,   625 
hot  saline  injections,  627 
oiled-silk  jacket,   477 
Diaphyses,  scur^'y,  66 
Diarrhoea,  244 

as   a   symptom  of  disease,  245 
complicating  measles,  596 
in  diphtheria,  515,  526 
in  malarial  fever,   670 
in  syphilis,  675 
in  typhoid,  649,  653 
fat,  241 
nervous,  245 
summer,  262 
Diastase,  167 

test  for,  227 
Diastatic  enzyme,   in  human   milk,   63 
in  intestinal  contents,  82 
in  stool  of  nursling,  82 
Diastolic   murmurs,   331 


Diazo  reaction,  in  tuberculosis,  493 
Diet- (see   Feeding), 
antiscorbutic,  145 
from  1  year  to  15  months,  162 
from  18  months  to  3  years,  163 
from  3  years  to  10  years,  163 

articles  allowed,   164 

articles    forbidden,    165 
in  acute  gastric  catarrh,  222 
in   auto-intoxication,   285 
in  chlorosisi,  697 
in   constipation,   270 
in  diarrhoea,  246 
in  diphtheria,   539 
in   dysentery,  253 
in  gastritis,   chronic,   229 
in  gastro-duodenitis,  228 
in   intestinal   indigestion,    227,    363 
in  lithsemia,  709 
in  pellagra,   255 
in   pleurisy  with   effusion,  439 
in  pyelitis,  378 
in  rachitis,  230 

See  Vitamines,   144 
in  scarlet  fever,  702 
in  scurvy,   302 

See  Vitamines,   144 
in  tonsillitis,  404 
in  tuberculosis,   497 
in  typhoid,  656 
in  ulcer  of  the  stomach,  235 
of  a  nursing  mother,  94,  96 
of  a  wet-nurse,   103 
salt-free,  624 
Dietary,  868 

Diffuse   cellulitis,   in   scarlet  fever,    613 
Digestive   system,   diseases   of,   205 
Dilatation  of  the   colon,   272 
Dilatation  of  the  stomach,  230 

in  chronic  gastritis,  228 
Diphtheria,  acute,  502 
bacillus,  502,  503,  505 

in  bronchitis,  425 

Klebs-Loeffler,  503 

characteristics    of,    504 
growth  on  blood   serum,   505 

true  and  false,  506 
bacteriology,  503 

mixed  infection,  538 

mode  of  infection,   502,   504 
chronic,   541 

isolation  in,  542 

treatment,    577 
complications,  523 

anaphylaxis,  517,  556 

measles,   596 

omphalitis,  35,  512,  526 

paralysis,  524,  540 

scarlet  fcA^er,  608,  628 
course,   511,   528 
diagnosis,   519 

how  to   take  a   cultvire,   519 

premembranous    stage,    519,    520 
differential   diagnosis,   521 
etiology,  502 


INDEX. 


923 


Di|)litli('iia,  oxti,il)ation,  572 
follicular  forms,  515 
iiiiiiuinizatioii  in,  5.'il 
intubation   in,  542 
isolation,  530 
mild,  512 
nasal,  513 
pathology,  507 
blood, "508 

liaMuorrhagew,  508,  524 
lesions,  507 
lymph-nodes,  508 
Diphtheria,   pathology,   membrane,  507 
predisposing  factors,  502 
prognosis,  437 
pro|)hylaxis,  529 
pseudo  or  false,  500 

mortality,   501 
septic,  512 
symptoms,  511 

toxin,  effect  of,  on  nervous  system  of 
animals,   510 
on  heart,   511 
tracheotomy,   574 
treatment,   533 
antitoxin,  539 
dietetic,   538 
hygienic,  524 
medicinal,    539 
Diphtheria   antitoxin,   539 
iiDiuunizing  dose,  531 
influence  of,  on  mortality,  546 
in    treatment    of*  membranous    oph- 
thalmia,  807 
limitations  of,  531 
manner   of   administering,    534 
rashes,  515 

anaphylaxis,   517 
desquamation    following,    519 
site  of  eruption,  517 
Diphtheritic  colitis,  251,  252 
conjunctivitis,    821 
dysentery,  252 
oesophagitis,  217 
omphalitis,   35,  512 
paralysis,  526,  527 

simulating     anterior      poliomyelitis, 
527 
rhinitis,  511 
stomatitis,  209 
Diphtheroid,  500 
Diplegia,  haemorrhage  causing,  736 

spastic,    795 
Diplo-bacillus    of   Morax,    820 
Diplococcus,    Fraenkel,    in   broncho-pneu- 
monia,  430 
in  lobar  pneumonia,  461 
intracellularis,   787 
pneumoniae,  430 

in   broncho-pneumonia,   430 
in    pleurisy   with   effusion,   430,   437 
stain   for, '889 
Disease,   diagnosis   of,    10,    12 
peculiarities   of,   9 
symptoms  of,  9,  12 


Disinfection,   894 

in  diphtheria,  528 

in  infectious  diseases,  894 

in   scarlet  fever,  023,   895 

in   typhoid,   656 

in   variola,   642 

of  sputa,  895 

of  urine  and  faeces,  895 

of  water  closets,  895 
Dislocation  of  the  hip,  congenital,  862 
Displacement,  of  the  heart,   842 

of  the  liver,   348 

of  the  spleen,  352 

of  tlie  stoiiiach,  232,  234 
Diverticulum,  Meckel's,  37 
Dobell's  solution,  393 
Drager  pulmotor,  48 
Drop   foot  in   paralysis,   773 
Dropsy  (see  also  CEdema  and  Anasarca), 

of  the  feet,  in  leukaemia,  694 
Drug  eruptions,  617 

resembling  measles,  596 
Drugs,   administration  of,   895 
per  rectum,  898 

dosage  of,  909 

effect    of,    on    woman's    milk,    88 

in  treatment  of   constipation,   269 
Dry  cupping   (see  also  Cupping),  897 
Dry  pleurisy,   436 
Dry-tap  in  lumbar  puncture,  790 
Ductless  glands,  diseases  of,  719 
Ductus  arteriosus  Botalli,   334 

closure  of,    326 
Duke's  disease,  583 
Duodenal  bucket,  224 

catarrh,    276 
Dura  mater,  inflammation  of,   794 
Dysentery,  251 

pathology,  251 
symptoms,  253 
treatment,  254 

amoebic,  251 

diphtheritic,  252 
Dyspepsia,   168,  219 
Dyspeptic,  asthma,  236 
Dyspnoea,    in   broncho-pneumonia,   434 

in  croup,   418 

in   dilatation   of   stomach,   231 

in   diseases  of  thymus,   691 

in  dry  pleurisy,  437 

in    hydropericardium,    343 

in  lobar  pneumonia,  475 

in   papilloniata,   846 

in  pulmonary   tuberculosis,   481 

in   retro-pharyngeal   abscess,  416 

in  toxic  scarlet  fever,  606 

in  tuberculous  pneumonia,  478 

oxygen  in,  476 
Dysiiria,  881 

Ear,  diseases  of,  812 

foreign  bodies  in,  818 

syringe,  814 
Earache,  in  diplitheria,  538 

in  scarlet  fever,  628 


934 


INDEX. 


Ears,   bleeding  from,   in   diphtheria,   524 
in  diphtheria,  515,  523 
in  scarlet  fever,  628 
iniiammation   of,   in   otitis,    812 
running,   in   syphilis,   680 
Eberth's  typhoid  bacillus,   646 
Ecchymoses,    in   purpura,   705 
in  purpura  hsemorrhagica,  706 
in  scurvy,  303 
Eclampsia    (see    also    Convulsions),    739 

in  epilepsy,  760 
Ectogenous    streptococcus    infection,    658 
Ectopia   vesicae    congenitalis,    378 
Eczema,  827 

associated  with   chronic   gastritis,   229 
bathing  in,  828 
in  lithsemia,  709 
intertrigo,  829 
rubrum,    829 
Effusion,  in  ascites,  359 
in  hydrocephalus,   774 
in    nephritis    following    scarlet    fever, 

626 
in   pericarditis,   340 
in  pertussis,  457 
in  pleurisy,  438 
Eggs,  nutritive  value  of,   199 
Eiweiss  milch,   140 
Elbow-joint  disease,   865 
Electricity,   in  cerebral   paralysis,   800 
in   chorea,   748 
in  constipation,  272 
in  enuresis,   390 
Emaciation,    in    dilatation   of   the    stom- 
ach, 231 
in  gastritis,  229 
in  hydrocephalus,  776 
in  myelitis,  764 
in  tuberculosis,  493 
Embolism,  in  endocarditis,  338 

in  diphtheria,  524 
Embolus,   in   endocarditis,   337 
Emetics,  in  bronchitis,  427 
in   croup,   444 

in  dyspnoea  or  broncho-pneumonia,  434 
in  gastric  catarrh,  220 
Emphysema,  complicating  diphtheria,  544 

complicating   pertussis,   457 
Empyema,  439 

complicating  diphtheria,   523 

complicating  measles,  595 

James  apparatus  for  expanding  the 

lungs  in,  443 
of  the  mastoid  antrum,  complicating 

scarlet  fever,  610 
treatment,  443 

Kenyon's   syphon   drainage,   442 
surgical,  442 
chronic,   443 
tubercular,   444 
Enanthem,     in    scarlatina    sine    angina, 
608 
in  scarlet  fever,  604 
in   measles,   586 
Eneephalocele,    777 


Enchondromata,  846 
Endocarditis,  335 

complicating  chorea,   746 
complicating   diphtheria,   523 
complicating    rheumatism,    700 
following  scarlet  fever,  624 
following  typhoid,   654 
symptoms,  336 
treatment,    338 
malignant,  338 
Enemata    (see  Rectal   Irrigations), 
in  chronic  gastritis,  228 
in  constipation,  269 
nutrient    (see  JRectal  Feeding), 
oxgall,  228 
Enteralgia,  273 
Enteritis,  croupous,  252 

membranous,    complicating   diphtheria, 

525 
tuberculous,   486 
Enuresis,  389 

a    symptom    of    faulty    metabolism, 

299 
a  symptom  of  lithsemia,  709 
causes,  389 

adenoids,   389,   412 
tight  prepuce,   389 
in  meningitis,  786 
prognosis,   389 
treatment,  389 
diurna,  389 
noctuma,  389 
Enzymes,   145 

Eosinophiles,   in   pneumonia,   687 
in  scarlet  fever,  687 
in  skin  diseases,  687 
in  syphilis,   687 
Epidemic  catarrhal  fever,  395 
cerebro-spinal  meningitis,  784 
hysteria,  750 
Epilepsy,  760 
aura  in,  761 
differential    diagnosis,    762 

from  hysteria,   762 
etiology,   760 

following  convulsions,   760 
predisposing   factors,    760 
symptoms,  762 
treatment,  763 
grand  mal  form,  761 
idiopathic,  760 
petit  mal  form,  761 
Epiphyses,  in  rachitis,  314,  315,  316 

in  syphilis,  681 
Epiphysis,  acute,  866 
Epispadias,  365 
Epistaxis,  in  haemophilia,  710 
in  measles,  598 
in  pertussis,'  455 
in   pulmonary  tuberculosis,  481 
in  septic  diphtheria,  513 
in  thrombosis  of  cerebral  sinuses,   818 
in  toxic  scarlet  fever,  606 
Epithelial   desquamation   of  the   tongue, 
214 


INDEX. 


925 


Erb's  paralysis,   43,   774 
Eructations,   in   chronic   gastritis,   229 

in   gastroptosis,   232 
Eruption,  artificial,  20 

drug,  resembling  measles,  596 
following  injection  of  diphtheria  anti- 
toxin, 516 
in  chloasma,  878 
in  influenza,  397 
in  measles,  585,  893 
in  meningitis,  786 
in  poliomvelitis,  771 
in  rubella,  578 
Eruption,  in  scabies,  841 
in  scarlet  fever,  608 
in   stomatitis   aphthosa,   206,   207 
in  syphilis,   676 
in  typhoid,  651 
in  vaccinia,  645 
in  varicella,  633 
in  variola,  639 
Erysipelas,  658 
blood   in,    687 
complications,  746 
in  the  new-born,  55 
treatment,   661 
vaccine,  452,   660 
migrans,  659 
Erythema,  830 

differentiated   from   syphilis,    676,    830 
following  injection  of  diphtheria  anti- 
toxin,  516 
on  buttocks,   829 
Erythroblasts,   684 
Erythrocytes,   683 
Eskay's  albuminized  food,  188 

analysis   of,    189 
Estlander's    operation     in     chronic     em- 
pyema,  444 
Ether  as  an  anaesthetic,  891 
Ethyl  chloride,  891 
Eucasin,   194 

Eustachian     tube,     in     adenoid     vegeta- 
tions,  411 
in  otitis  media,  812 
inflammation   of,   in   rhinitis,   299 
Examination  of  heart,  326 
of  lungs,  423 
of  patient,  9 
radiographic,   16 
Exercise    (see  also  Gymnastics),  23 
in  constipation,  271 
in  lithsemia,  709 
Exophthalmia  in  thrombosis  of  cerebral 

sinuses,   818 
Exophthalmic  goiter,  731 

treatment,   731 
Exophthalmus,    in    exophthalmic    goiter, 
731 
in  hydrocephalus,  775 
Expectorants,  in  l)roncho-pneumonia,  435 
Expectoration    ( see   Sputum ) . 
in  bronchitis,  426 
in  pulmonary  tuberculosis,   481 
in  ulcer  of  stomach,  234 


Exploratory   puncture,   in  empyema,   440 
in   pleurisy   with   effusion,   438 
points  to  be  rioted  in  making,  440 
Exstrophy  of  the  bladder,  378 
Extubation,  572 

auto-,.  543 
Eye,  as  a  diagnostic  aid,   12 

diseases  of,  819 

in  chlorosis,  696 

in   chorea,   745 

in    distinguishing   the    still-bom    from 
the  dead,  46 

in  exophthalmic  goiter,  731 

in  gonorrhcpal   infection,  3G8 

in  measles,  585,  595 

in  meningitis,  783 

in  nystagmus,  786 

in  stomatitis  gangrsenosa,  210 

prophylaxis   and  treatment  of,   in   the 
new-born,  34 

suffusion  of,  in  rubella,  578 
Eyelid,  in  blepharitis,  824 

in  hordeolum,  825 

in  purulent  ophthalmia,  821 

in  trachoma,  824 

method  of  everting,   825 

proptosis  of,  in  scurvy,  303 

Face,  cyanosis  of,  in  broncho-pneumonia, 
431 
in  adenoid  vegetations,  411 
in  chlorosis,   696 
in  cretinism,   719,   720 
in  diphtheria,  septic,   512 
in  nephritis,  372 
in  pertussis,   456 
Facial    paralysis,    following   mastoid   op- 
eration, 802 
in   retro-pharyngeal   abscess,   802 
in  the  new-born,  802 
Faecal  vomiting,  286 
Faeces   (see  Stools). 
Fainting    (see  Syncope). 

in  leukaemia,  694 
Fat,  absorption  of,  74 

cream  gauge  for,  134 
Feser's  test,  134 
Marchand's  test,  134 
in  breast  milk,   104 
to  decrease,  104 
to  increase,   104 
in  cows'  milk,  132 

excess  of,  132 
in  stool,  132 
Fatty  degeneration  of  blood-vessels,  796 
of  newly  born,  41 
in  pernicious  anaemia,   692 
growths,    846 
heart,   330 
liver,  349,  350 
Faulty  metabolism,  298 
catarrhal   tendencies,   299 
lienteric   stools,  298 
nervous   manifestations,   299 
scybalous  stools,  298 


926 


INDEX. 


Faulty  treatment,   299 
Feeble-mindedness    (see   also   Idiocy   and 

Imbecility),   806 
Feeding    (see  Diet  and  Gavage). 

bottle  or  hand,  150 
utensils  required,    150 

breast,  84 

buttermilk,   173 

caloric  method  of,   158 

Casselberry  method  of,   in   intubation, 
556,  557 

cows'  milk,   150 

cream,   146 

flour-ball,   166 

from  1  year  to  15  months,  107 

goats'   milk,   173 

in  atrophy  and  chronic  gastritis,  229 

in  bronchitis,  427 

in  cleft  palate,  58 

in  diphtheria,  538 

in   hypertrophic    pyloric   stenosis,    227 

in   intubated   cases,    556 

in  myocarditis,  345 

in  pertussis,  459 

in  pneumonia,  477 

interval  of,  84,  86 

malt  soup,  to  make,   160 

maternal,   85 

mixed,   87 

of  premature  infants,  30 

rectal,   427,   539 
Feeding  bottles,   150 
Femur  in  rachitis,  314 
Ferment,   lipolytic,   82 

tests,  225 
Fermentation,    in   chronic   gastritis,    228 

in  auto-intoxication,  285 

test  in  urine,  885 
Ferments   and  their   actions,   67 

unorganized,  66 
Feser's   lactoscope,    134 
Fever    ( see  also  Temperature ) ,  445 
causes,  445 

hay,  428 

how  to  reduce,  474 
hysterical,  447 
in  faulty  metabolism,  299 
in   gastric  catarrh,  223 
in   tonsillitis,   407 
Fingers  in  cretinism,  719. 
First    attempts   at   walking,    2 
Fissure  of  the  anus,  294 
Fistula  in   alveolar   abscess,   216 
Flatfoot,  854 

Flatulence,  in  gastro-duodenitis,  226 
Flaxseed  poultice,  896 
Flexner   anti-meningitis   serum,   791 
Flour-ball   feeding,    166 
Focal  necrosis,  350 

Foetal    (see  also  Congenital)    circulation, 
325 

ichthyosis,   50 

typhoid,  647 
Foetus,  in  syphilis,  672 
Follicular  formsi  of  diphtheria,  515 


Follicular  forms  of  tonsillitis,   404,   522 

resembling  diphtheria,  521 
Fomentations,   896 
Fontanel,  733 
anterior,  733 
in  cretinism,   719 
in  hydrocephalus,   776 
in  rachitis,  308,  312 
posterior,  733 
premature  closure  of,  733 
Food,   dextrinized,   167 
method  of  preparing,  167 
intoxication,  255 
Foods,  infant,   182 
patent,  181 

composition      of,      compared      with 
human  milk,   193 
Foot  and  mouth  disease  (see  also  Stoma- 
titis Aphthosa),  206 
Foramen    Magendie,     in    hydrocephalus, 
736 
ovale,  closure  of,   326 
Foreign  bodies  in  the  ear,  818 
in  the  larynx,  421 
in  the  nose,  402 
in'  the  oesophagus,  218 
Formaldehyde  in  milk,   119 

test  for,   119 
Formulae   for   bottle-fed   infants,    161 
Fourth  disease,  583 
Fractures,   43  . 

during  labor,  43 
green-stick,  43 
in   rachitis,   314 
Fraenkel     diplococcus,     in     lobar     pneu- 

,   monia,   461 
Freckles,   834 

Friedreich's  disease   (see  also  Hereditary 
Ataxy),  767 
sign,  in  chronic  pericarditis,  342 
Fright,  causing  chorea,  745 
causing  convulsions,   739 
Furuncle,  835 

differential    diagnosis    from   carbuncle, 

835 
in  rachitis,  835 
in  syphilis,   676 
vaccine  treatment,   451,   835 

Gall-bladder,  congenital  absence  of,  37 
Gall-stones,  348 
Gangrene,    839 

complicating  erysipelas,  659 

complicating    pneumonia,    472 

complicating  typhoid,   654 

of  cheeks,  210 

of  genitals,  211 

of  mouth,  654 

pulmonary,   482 

superficial,  839 

symmetrical,   841 

traumatic,  840 
Gastric  catarrh,  219 

contents,   examination   of,   875 

fever,  resembling  typhoid,  654 


INDEX. 


927 


Gastric    juice,    chemical    constituents   of, 
65 
influence    of,    on    pathogenic    germs, 
66,  67 
Gastritis,  acute,  219 

complicating    diphtheria,    524 
chronic,  228 
treatment,  229 
Gastrodiaphane    for    translumination    of 

stomach,   231 
Gastro-duodenitis,  228 
Gastroenterostomy     in     spasm     of     the 

pylorus,  224,  226 
Gastro-intestinal      disturbance,      causing 
asthmatic  attacks,  428 
haemorrhage,   41 
tract,  in  syphilis,  675 
Gastroptosis,    232 
Gavage,  apparatus  for,  31 
in  cleft  palate,  58 
in  intubated  cases  of  diphtheria,  556 
method    of,    in    premature    infants,    32 
Gelatine   food,    871 
General  hygiene  of  the  infant,   17 
Genital  organs,  diseases  of,  361 
in  phimosis,  363 

irritation  in  chronic  cystitis,  387 
Genu  recurvatiun,  320 

varum    (see  also  Bowlegs),  320 
Geographical  tongue   (see  also  Epithelial 

Desquamation ) ,    214 
Gerhardt's  iron  chloride  reaction,   886 
German   measles,    577 
Gestures   as   diagnostic   aid,    13 
Ginger   poultice,   897 
Gingivitis,  6 

in  scurvy.  303 
Gland,  thymus,  711,  712 

thyroid,  719 
Glands,  adrenal,  732 

bronchial,    in    broncho-pneumonia,    432 
enlarged,  causing  bronchial  asthma, 
428 
cervical,  299 

causing  torticollis,  705 
in   stomatitis  gangrsenosa,   211 
diseases  of,  711 
in  adenitis,  712 
in  eczema,   827 
in  leuksemia,  693 
in  mumps,  716 
in  rubella,  578 
in  scarlet  fever,  604,  628 
in  status  lymphaticus,  711 
peripheral,   in   acute   tuberculosis,   493 
submaxillary,   in   diphtheria,   512 
in  scarlet  fever,  604 
Glomerulo-nephritis,  370 
Glossitis,   215 

Glottis,  oedema  of,  in  erysipelas,  660 
in  scarlet  fever,  631 
in  variola,   642 
spasm  of,  causing  cough,  421 
Glucose  in  iirine,   884 
Glycosuria,  383 


Glycosuria,   in   .lialn-tes  mellitus,   384 

in    pseudo-hyportrophic   paralysis,    880 
Goats'  milk,  173 
Goiter,  exophthnlmic,   731 

wet-nurse  with,   98 
Gonococcus,  367 

in  cystitis,   387 

in  gonorrheal  vaginitis,  307 

stain  for,  889 

vaccine,  452 
Gram's  solution,  889 
Granular  gastritis,  228 

ophthalmia,    822 
Granular  ophthalmia  from  false  or  fol- 
licular granulations,  823 
Granuloma,  35 
Granulomata,   847 

Graves's  disease    (see  also  Exophthalmic 
Goiter),  731 

sign  in  bronchitis,  426 
Grippe    (see   also   Influenza),    395 
Growing  pains,  699,  701 
Growth  and  height,   5 

in  diabetes  insipidus,  383 
Growths,  malignant,   842 

non-malignant,   842 
Giiaiacum  test  for  blood  in  urine,  886 
Gums,     bleeding,     in     purpura     hsemor- 
rhagiea,  706 

inflamed,    6 

possible      source      of      invasion     of 
tubercle  bacilli,  485 

in  scurvy,  303 

in  stomatitis  gangrsenosa,  211 

in  toxic  scarlet  fever,  620 
Gymnastics    (see  also  Exercise),  23 

in  lateral  curv-ature,  859 

pulmonary,  498 
in  empyema,  443 
in  tuberculosis,   498 

Habit-spasm,   differential  diagnosis   from 

true  chorea,   746 
Hsematoma  of  the   sterno-mastoid,   61 
Hsematuria,   382 

in  cystitis,  387 

in  malarial  fever,  670 

in  purpura  haemorrhagica,  706 

in  pyelitis,  379 

in  scurvy,  302 

in  symmetrical  gangrene,  841 
Haemoglobin,  at  birth,   684 

in  diphtheria,  510 

in  rachitis,  684 
Hsemoglobinuria,  382 

in  malarial  fever,  676 

in   symmetrical   gangrene,   841 

in  syphilis,  880 

in  Winckel's  disease,   880 

neonatorum,   40 

paroxysmal,  382 
Haemophilia,   709 
Haemoptysis,  in  chronic  tuberculosis,  481 

in   purpura  haemorrhagica,   706 
Haemorrhage,  cerebral,  in  pertussis,  455 


§^§ 


INDEX. 


Haemorrhage,    follo^ving    adenoid    opera- 
tion, 415 
following    operation    for    peritonsillar 

abscess,  407 
following  tonsillotomy,   408 
from  bowels,   694 
from  genital  tract,  382 
from  kidney,  382 
from  stomach,   694,   731 
gastro-intestinal,  41 

serum  injections  in,   42 
in  congenital   obliteration  of  the  bile 

duct,  38 
in    diphtheria,    513,    524 
in   leukaemia,   693 
in  pachymeningitis,   794 
in  syphilis,  765 
in  typhoid,  653 
into  subarachnoid  space,   736 
spontaneous,    39 
subcutaneous,   in  scarlet  fever,   506 

in  scurry,   303 
umbilical.  40 
Haemorrhagic     diseases     of     the     newly 

born,  39 
Haemorrhoids,  298 
Hair,   1 

in  cretinism,  719 
Hand-feeding    (see    also    Bottle-feeding), 

150 
Hands,  disinfection  of,   894 

in  cretinism,  720 
Harelip,  58 
nipple,  58 
Hay  fever,  428 

resembling  bronchial  asthma,  428 
Head,  circumference  of,  at  birth,  733 
in  hydrocephalus,   776 
in   rachitis,   308 
nodding,   in   spasmus  nutans,   743 
retraction  of,  in  cerebro-spinal  menin- 
gitis, 786 
shape  of,  733,  734 
supplementary,  62 
sweating,   311 
Headaches,  742 

due  to  brain   lesions,   743 

to   general   systemic   conditions,   742 
to  influenza,  396 
to  local  origin,  742 
in   chlorosis,   696 
in  chronic  gastritis,  229 
in   diabetes   insipidus,    383 
in  lithaemia,   709 
in  tubercular  meningitis,  783 
reiiex,  742 

sick    (see  also  Migraine),  743 
Heart  and  fcetal  circulation,  325 
Heart,  325 

diseases  of,   329 
displacement  of,   842 
eflFect  of  exercise  on,  24 
examination  of,   327 
area  of  dullness,  328 
location  of  apex  beat,   326 


Heart,   fatty,   330 
in  chorea,  747 
in   diphtheria,   541 
in   gonorrhoeal   infection,   368 
in  pertussis,  456 
in  rheumatism,  700 
in  scarlet  fever,  617,  620 
murmurs,  330 
anaemic,  331 
diastolic,    331 
pericardial,  333 
systolic,  330 
venous,  332 
palpitation  of   (see  also  Tachycardia), 

330 
position  of,  327 
primary  tuberculosis  of,  486 
reflex  symptoms  of,  330 
size  of,  "326 

sounds  and  murmurs,  330 
tension,   327 

tricuspid  insufficiency,  331 
weight  of,   326 
Heat-stroke    (see  also  Insolation),  246 
Hehner's  test  for  formaldehyde  in  milk, 

120 
Height,  5 

Heliotherapy,   15,  498 
Heller's  test  for  blood  in  urine,  886 
Hemichorea,  746 

Hemicrania    (see  also  Migraine),   743 
Hemiplegia     (see    also    Cerebral    Paral- 
ysis),  795 
complicating   diphtheria,    523 
haemorrhage    into    subarachnoid    space 
causing,  736 
Hemostatics    in    acute    tuberculosis,    498 

in  internal  haemorrhage,  42 
Hepatic   abscess,   caused  by   worms,   290 
Hereditary  ataxy,   766 

s}T)hilis,  680 
Hernia,  361 

differential    diagnosis    from    hydro- 
cele, 362 
in  the  new-born,   361 
umbilical,  288 
truss,  289 
Herpes,   circinatus,  837 
tonsurans,   837 
zoster,   831 
Hiccough    (see   Singultus). 
Hinged    bucket    for    extracting    foreign 

bodies,  218 
Hip,  congenital  dislocation  of,  862 
bilateral  dislocation  of,  863 
unilateral    dislocation   of,    863 
Hip- joint     disease      (see     also     Morbus 
Coxarius),  861 
from   perinephritis,  375 
tubercular,  861 
Hips,   in  lateral  curvature  of  the  spine, 

855 
Hirschsprung's  disease,  272 
Hives    (see  also  Urticaria),  830 
Hoarseness,  in  syphilis,  680 


INDEX. 


929 


Hodgkin's  disease,   716 
Home  modification  of  milk,   150 
Hookworm   disease,   293 
Hordeolum,  825 
ITorismascope,   882 
Horlick's   food,    185 
lunch  tablets,   164 
malted  milk,   184 
Hot-air  bath,  621 

compresses  or  fomentations,  896 
Hot  and  cold  bath,  in  asphyxia  neona- 
torum, 47 
Human,  blood  serum,  39 
milk    (see  Woman's  Milk), 
diastatic  enzyme  in,   82 
new  reaction  of,  82 
properties   of,   76 
to  preserve,  83 
Humanized  milk,   192 
Hutchinson's   teeth,   676 
Hydrencephalocele     (see     also    Meningo- 
cele), 777 
Hydrencephaloid,  308 
Hydrocele,  363 
Hydrocephahis,  776 
external,  776 

foramen  Magendie   in,   736 
internal,  776 
intra-uterine,  777 
spurious,  308 
Hydrochloric  acid,  function  of,  in  stom- 
ach, 66 
in  gastric  contents,  875 
test  for  formaldehyde  in  milk,  120 
Hydropericardium,  343 
Hygiene,  of  infant,  17 
fresh  air,  21 
proper  training,  23 
of  mouth,   17 
nervous  system,  23 
stable,   126,   127 
Hypersemia,   cerebral,   in   insolation,   250 
Hyperaesthesia,   in  acute  myelitis,   764 

in  multiple  neuritis,  752 
Hypernephroma,   845 
Hyperorexia    (see   also   Biilimia),   232 

in   acute   tuberculosis,   493 
Hyperthyrea      (see     also     Exophthalmic 

Goiter),   731 
Hypertrophic   pyloric   stenosis,   226 
gastro-enterostomy    in,    227 
tonsillitis,  405 
treatment,  409 
Hypertrophy  of  muscles,  802 
of  tongue,  214 
of   tonsils,   407 
Hypodermic  medication,   908,  909 
in  spasmodic  laryngitis,  420 
Hypodermoclysis,   in   scarlet  fever,   626 

in  typhoid,  655 
Hypospadias,  365 
Hysteria,   749 

differential  diagnosis  from   epilepsy, 

762 
pathology,   749 


Hysteria,   tr<-:»tnif'nt,  750 

epidemics   of,   750 
Hysterical  fever,  450 

Ice-bag,  throat,  404,  407 
coil,  in  meningitis,  78:5 
Ice  cream,  201 
Ichthyosis,  fa'tal,  50 
Icterus,  346 

complicating    pseudo-leukajmic    aiKC- 

mia,  695 
complicating  scarlet  fever,   619 
urine  in,  878 
neonatorum,   52 
Idiocy,   806 

congenital,   807 

infantile   amaurotic   family,   810 
Mongolian,   807 
Ileo-colitis    (see  also  Dysentery),  251 
Imbecility,  806 
Immunity    conferred    by    woman's   milk, 

82 
Immunization   in   diphtheria,   531 
Imperforate  rectum,  63 
Imperial  granuni,   187 
Impetigo,   833 

resembling  varicella,   635 
resembling  variola,   641 
Improper  nutrition,  298 
Inclusion  bodies  in  blood  of  scarlet  fever, 

602 
Incubators,  27,  33 
Indican,  in  tubercvilosis,   493 

test  for,   in  urine,   884 
Indicamiria,   289,  380 
Indigestion,   chronic  intestinal,   276 
Infancy  and  childhood,   1 
Infant,   foods,    182 
mortalitv,    14 
stools,  237 
Infantile  atrophy,   321 
spinal  paralysis,  76S 
Infarction,    uric    acid    in    kidneys,    878, 

880 
InfectioTis  diseases,  445 

table  of,  448,  449 
Inflamed  gums,   6 

source    of    invasion    of    tubercle    ba- 
cilli, 485 
Inflammation  of  the  dura  mater,  794 
Inflammatory      rheumatism       (see      also 

Eheumatism),   698 
Inflation,    of    bowel,    in    intussusception, 
288 
of   limgs,   47 

of  stomach,  in  gastroptosis,  233 
Influenza,   395 

bacteriology  of,   395 
complications  of,   299 
diagnosis,   397 
eruption,  397 
isolation,  400 
symptoms,   396 
treatment,  400 
gastro-enteric  type,  398 


59 


930 


liSTDEX. 


Influenza,  nervous  type,  398 

respiratory  type,   398 
Inhalations,  in  asthma,  429 
in  bronchitis,  427 
in  crouj),  419 
Injections    (see   Eectal    Injections), 
of  horse  serum,  33,  42 
intrahiryngeal,    419 
intravenous,  536 

in  erysipelas,  661 
subcutaneous,    in    scarlet    fever,     627, 
632 
Insolation,  246 

differential      diagnosis      from      menin- 
gitis, 246 
Insomnia    (see  Restlessness  at  Night). 
from  use  of  coffee,  202 
in  cretinism,  724 
in  gastroptosis,  232 
in  hysteria,   750 
Intermittent    fever     (see    also    Malarial 

Fever),   662 
Interstitial  hepatitis,  350 
Intertrigo   eczema,    829 
Intestinal   colic,  273 
hsemori'hage,   42,   650 
indigestion,  273 

chronic,  276 
obstruction,   from  intussusception,  284 

in  constipation,   267 
perforation,   in  typhoid,   649,   653 
Intestines,   72 

abnormalities  of,   267 
caecum,   73 
course  of  colon,   73 
sigmoid  flexure,   73 
transverse  colon,  73 
vermiform  appendix,  73 
absorption  of   fat  in,   74 
bacteria  of,  243 
formation  of  gas  in,  74 
haemorrhages   from,   653,   731 
perforation  of,   753 
Intoxication,  food,  256 
Intracranial   injections,   792 
Intraspinal   aniiesthesia,   892 

injections,  792 
Intravenous    injections,    536 

in   erysii5clas,   661 
Intraventricular    method    of    serum    in- 
jections, 7SS 
Intubation,   542 

false  passage  in,  553,  571 
in  aphonia  spastica,  554 
in  cicatricial  stenosis,  553 

due  to  syphilis  or  trauinatism,  553 
in   deformities  of  larj-nx,   554 
in  diphtheria,   542 
accidents  during,  553 
after-effects  of,  563 
effect  of,  in  upper  air  passages,  5G0 
false  passage  in,  571 
feeding  in,  556 

Casselberry  method,   556,   557 
indications  for,   544 


Intubation,     in    diphtheria,    method    of, 
547 
mortality,    544 

in  papilloma  of  larynx,  554 
Intubation    instruments,    545     • 

specially    constructed    rubber    tubes, 
545,   554 
Intussusception,    285 

colic,  285 

ileo-colic,   285 

ileo  or  jejunal,  285 
Invagination   of   bowel    (see   also   Intus- 
susception),  284 
Invertin,   function   of,   67,    135 
lodophile   reaction   of  blood,    686 
Iritis,   in  meningitis,   786 
Irrigation    (see   Rectal    Irrigation). 
Irrigation,  chamomile,  in  dysentery,  352 

cold-water,  in  constipation,  269 

in  vaginitis,  618 

nasal,  631 

of  bladder,  387 

of  colon,  in  typhoid,  629 

saline,  in  diarrhoea,  245 
Ischio-rectal  abscess,  295 
Isolation,    in    diphtheria,    529,   542 

in  influenza,   448 

in   measles,    596 

in  mumps,  718 

in  pertussis,   355 

in   scarlet   fever,    623 

in   syphilis,   681 

in   varicella,    336 

in   variola,    642 
Itching,   in  scabies,   841 

in  scarlet  fever,  623 

in  variola,   642 

Jacket,  pneumonia,  434,  435 

James's    apparatus    for    expanding    the 

lung,  443 
Jaundice    (see   also   Icterus),    52,   346 

catarrhal,  228 
Jaw,   in  alveolar  abscess,  216 
in   angina  Ludovici,   216 
in  tetanus,   758 
necrosis  of,   in   stomatitis  gangreenosa, 

211 
upper,  in  syphilis,  676 
Joints,  diseases  of,  848 

in    gonorrhoeal    infection,    368 
in  haemophilia,  710 
in  meningitis,   786 
in  purpura  rheumatica,   706 
in   rheumatism,   699 
scrofulous,    486 
Junket,  871 
Just's    food,    191 

Keller's  malt  soup,   166,   870 

Kenyon's   sj^phon   drainage   in   empyema, 

442 
Keratitis,  in  measles,   595 

in    meningitis,    786 
Kernig's  sign,   786 


INDEX. 


931 


Kidney,  falcnH   in,   386 
fonj^cnital  cyst  of,  62 
.lilatation    n'f,   .377 
(I  i  sea  SOS  of,   370 
li.nnmorrliarro   from,   382 
inllaiMiiiation   of,    371 
in   7ic\v-born,   878 
in   p,ye]itis,   37 S 
in  scarlet  fever,  014,  620 
position    of,    in    infancy,    370 
sacculation  of,   377 
Klcl)s-Ix)emer    bacillus,    .502,    .503 
in    (liplitheritic    omphalitis,    35 
in  measles,  502 

in    membranous   conjunctivitis,    821 
smear   i)roparation,   505 
stain   for,   889 
Knee,  in  morbus  coxarius,  861 

in   rachitis,   316 
Knee-jerk    (see   Patellar   Reflexes). 

in   multiple   neuritis,   752 
Knee-joint  disease,    85 

differential     diagnosis     from     rheu- 
matism,. 864 
in  morbus  coxarius,   861 
in   rachitis,   316 
Knock-knee,   in   rachitis,   316 
Koplik's  sign  in  measles,   587 
Kyphosis,  855 

in  Pott's  disease,  848 
in  rachitis,   314 

Lab  ferment,   65 

action  of,  on  milk,  76,  77 
Laboratory    modification    of    milk     (see 

also   Percentage   Feeding),    170 
Lachrymal     duct,     inflammation     of,     in 

nasal  catarrh,  391 
Lactation,  massage  of  breasts  during,  94 
Lactic  acid,  in  buttermilk,  174 

in  gastric  contents,  875 

in  stomach,   66 

in  urine,    174 
Lactic   acid  bacillus,    174 
Lactoscope,   134 
Lactose,   1.36 

La  grippe    (see  also  Lifluenza),   395 
Lahmann's  vegetable  milk,  178 
Laparotomy,     in    intestinal    perforation, 
653  " 
in  intussusception,  288 
in    tuberculous   peritonitis,   358,    360 
Laryngeal  spasm,  756 

in   bronchial    asthma,    428 

in  rachitis,   312 

in   status  lymphaticus,   711 

recurring,  561 
Laryngeal    stenosis,    congenital,    60 

in   diphtheria,   512,   537,   542 

in    retropiiaryngeal    abscess,    416 

intubation,   in  chronic,   554 

specific,    following    intubation,    569 
Laryngitis,   complicating  measles,   592 
spasmodic,   417 


Laryngitis,    c|i;i;iM.i.i~    fioin    di[)lilhcritic 
croup,  417 
predisposing    fiu-tois,    418 
treatment,   419 
Larynx,   congenital   steno^i-   "''    60 

foreign  bodies  in,  420 

granulomata   of,    847 

growths    of     (see    also    Papillomata ) , 
846 

in   diphtheria,   512,   545 

intubation   in,   555 

tolerance   of,   for   intubation   tube,  554 

tracheotomy,   in   stenosis   of,   574 
Late  speaking,   3 

Lateral  curvature  of  the  spine,  855 
Lavage    (see   Stomach-washing). 
Lecithin,    199 

Leeches,   application   of,   to   relieve   cere- 
bral  congestions,   475 

in  convulsions,   741 

in   orchitis,   complicating  mumps,   717 

in  rheumatism,  702 
Leffert's   nasal   syringe,   .393 
Lentigo,   834 

Leptomeningitis     (see    also    Pachymenin- 
gitis),  794 
Leucocytosis,   684 

in    appendicitis,    281 

in   chorea,   687 

in  diphtheria,  508 

in  nervous  diseases,  687 

in   pneumonia,   467 

in   rachitis,   686 

in   scariet   fever,    604 
Leucomain    poisoning,    70S 
Leucoptenia  in   typhoid,   652 
Leukaemia,  693 

blood  in,   693,  694 

lymphatic  form,   693 

myelogenous  form,  693 

splenic  form,   693 
Lichen   tropicus,   833 

Liebermann    phenol    test    for    formalde- 
hyde in  milk,   122 
Lien  mobilis,  352 
Lime,  saecharated  solution  of,  143 

water,  in  modification  of  milk,  143 
Lingual    tonsil,    in    status    lymphaticus, 

711 
Lipoma,    846 

Lips,  cyanosis  of,  in  broncho-pneiunonia, 
431 

i^r  adenoid  vegetations,  411 

in  cretinism,  719 

in  septic  diphtheria,  513 
Liquor  potassre  test  for  pus  in  urine,  886 
Lisping,    744 
Lithffimia,  708 

diet  in,  709 

urine  in,   709 
Lithuria    (see  also  Lithsemia),  708 
Liver,   abscess  of,   347 

amyloid   degeneration   of    (waxy),   349 

cirrhosis  of,   350,   691 

descended,   .349 


932 


INDEX. 


Liver,   diseases  of,  346 

displacement   of,    348,    349 

in  constipation,  26S 
fatty,  349 

focal  necrosis  of,   350 
functional    disorders   of,    348 
in  congenital  obliteration   of  the  bile- 
ducts,  37 
in   diplitheria,   59,   515 
in  faulty  metabolism,  298 
in   gastro-duodenitis,   228 
in  leukemia,    693,   694 
in  malarial  fever,  667 
in   pseudo-leuksemic   angemia,    695 
in  scarlet  fever,  619 
in  tuberculosis,   493 
spots    (see  also  Cliloasma),  832 
■weight   of,   346 
Lobar  pneumonia,   460 
Lobular    pneumonia,    429 
Local   anaesthesia,   891 

bv  injection  of  sterile  water,  892 
blood  letting,   897 
remedies,   896 
Lock-jaw    (see  also  Tetanus),   758 
LoefHer's  bacillus,   504 
Loefflund's  malt  soup,   160 
Lordotic  albuminuria,  381 
Loss  of  speech  due  to  paralysis,  4 
Luetin  reaction,   678 
Lumbar   puncture,   783,   789 

amount    of    fluid   to   be    -withdrawn, 

790 
needle  required,  789 
place   for   puncture,   789 
dry-tap  in,   790 
in  convulsions,   741 
in  hydrocephalus,   777 
in    meningitis,    tubercular,    782 
epidemic   eerebro-spinal,   789 
infantile    spinal,    774 
Lung,   at  term,   1 
inflation   of,    47 
auscultation  of,  423 
cavities  of,   479 
compressed,   431 
cut  surface  of,  479 
gangrenous   infiltration  of,   211 
in  broncho-pneumonia,   432 
in   diphtheria,    610 
in  empyema,  440,  443 
in  lobar  pneumonia,  460,  461 
in  tuberculosis,   424 
in  wandering   pneumonia,   464 
percussion   of,   424 

points   in  examination  of,   423 
transverse   section   of,   480 
Lymphadenitis,    retropharyngeal,    415 
Lymphatic  glands    (Lymph  Nodes),   dis- 
eases of,  711 
enlarged,   causing   torticollis,    705 
in  anajsthesia,  891 
in   diphtheria,  508 

local,  512 
in  leukaemia,   693 


Lymphatic  glands,  in  mumps,  717 

in  pseudo-leuksemic   anaemia,   695 
in  retro-oesophageal  abscess,  217 
in   retro-pharyngeal   abscess,    415 
in  tonsillitis,  405 
in  tuberculosis,  493 
Lymphocytes,    increase    of,    after    second 
year,   684 
in  diphtheria,  687 
in  malaria,   687 
in  pneumonia,  687 
in  scarlet  fever,  687 
in  typhoid,   687 

MacEwen's    percussion    note,    733 
Maerocephalus,   in   epilepsy,   760 
Macrocytes,  in  syphilis,  685 
Mackenzie  tonsillotome,  409 
Magendie     foramen,     in     hydrocephalus, 

736 
Malarial  fever,  662 
blood  in,  667 
Plasmodia  in,   663 
symptoms,  670 
treatment,   671 
sestivo-autumnal,    665 
double  tertian,   662 
quartan,    664 
quotidian,   662 
tertian,  662 
Malformations   of   the   rectum,    63 

of  the  spinal  cord,  766 
Malignant,  endocarditis,  338 
growths,  842 

in  bladder,  387 
■  purpuric  fever,  784 
!Malt  extract,  in  summer  complaint,  167 
soup,  166 

to  make,  160 
[Malted  milk,  Horlick's,   184 
]\Ialtose,  67 

Mammal  a,  infant  food,   190 
]\rammary  glands,  54,  79 
Mannaberg's  table  of  malarial  parasites, 

669 
Marasmic  thrombosis,  818 
Marasmus,   321 

Marehand's  test  for  fat  in  milk,   134 
Massage,    method   of   performing,    272 
in  cerebral  paralysis,  800 
in  constipation,   271 
in   spinal   paralysis,   772 
of  breasts  during  lactation,  94 
vibratory,  271 
Mastitis  neonatorum,  54 
Mastoid   disease,   in   otitis  media,   815 
operation  for,   815 
facial  paralysis  following,   817 
Masturbation,   754 

treatment,   755 
^Maternal  feeding,  85 
Matzoon    (see  also  Zoolak),   198 
Measles,   584 

bacteriology,    584 
complications,   591 


INDEX. 


933 


Moaslcs,   diagnosis,    590 

from   drug  eruption,   596 
from    influenza,   596 
from   variola,    641 
immunity,   595 
incubation    period,    580 
mortality,   584 
sequelae,    tuberculosis,    486 
symptoms,  585 

desquamation,  588 
enanthem,  585 
eruption,  587,  588 
treatment,  596 
isolation,   596 
German,  577 

haemorrhagic   form,    590 
malignant  form,  589 
mild  form,  589 
relapsing  form,  589 
Meat  juice,  200 
Meckel's  diverticulum,   37 
Meconium,  237 

Medication,  points  concerning,  895 
hvpodermic,  908,  909 
local,   896 
rectal,  898 
Megacolon,   272 
Meig's  food,   198 
Melsena,  41 
Mellin's  food,  189 

Membrane,   in   diphtheria,   502,  512 
Membranous   conjunctivitis,   821 
Meningitis,  cerebro-spinal,   784 
bacteriology,  784 
complicating  diphtheria,  524 
diagnosis,  787 
etiology,  784 
lumbar  puncture  in,  786 
mortality,  785 
pathology,   784 
prognosis,  791 
symptoms,   785 

Brudzinski's    neck    sign,    786 
Kernig's  sign,   786 
treatment,  791 

serum,  792 
tubercular,   779 
bacteriology,  779 
course,  781 
diagnosis,  782 
etiolog}',  779 
lumbar  puncture  in,  783 
pathology,  779 
symptoms,   782 

Babinski   reflex,   783 
tache  cerebrale,   783 
treatment,   783 
jMeningocelo,  177 
Meningococcus,   784 

stain  for,  889 
Menstruation,     effect     of,     on     woman's 
milk,  75,  79,  99 
in   chlorosis,   696 
praecox,  369 
vicarious,   368 


Mental  faculties,  2 

Mercury,  administration  of,  to  children, 
211,  899 
in   treatment  of   sypliijls,   681 
Mcteorismus   (see  also   Intestinal  Colic), 

273 
Microcephalus,   craniectomy    in.   800 
fontanel  in,  729,  776 
in    chronic    hydrocephalus,    776 
in  epilepsy,  760 
Micrococcus   catarrhalis,    784,    787 

in   nasal   catarrh,   391 
Microcytes,  in  syphilis,  685 
Micro-organisms     (see    Bacteria). 
Middle-ear    abscess,    causing    abscess    of 

brain,  804 
Migraine,  743 
Miliaria  papulosa,  833 

ruljra,  834 
Miliary  tuberculosis,   483 
Milk,  albumin,  140 
Bulgarian,   174 
cows',    114 

addition  of  alkalies  to,  143 
adulteration  of,  119 

formaldehyde  in,    120 
albuminoids  in,   138 
analysis  of,   114,  115 
certified,  in  New  York  City,   118 
composition  of,   114 
condensed,   179 
diluents  of,   149 
eiweiss,   140 
enzymes  in,   145 
fat,  132 

home  modification   of,    150 
idiosyncrasy,    169 
infection,   256 
pasteurization   of,    156 
predigested  or  peptonized,   873 
protein  in,   137 
raw,   128,   129 
saltsi  in,  141 

skimmed  in  feeding  of  premature  in- 
fants, 33 
starch  in,   145 
sterilization  of,   152 

changes  caused  by,   153 
tuberculous    infection    through,    122, 

131 
imdiluted,  as  a  food  for  infants,  131 
variations  of,   114 
vitamines  in,  145 
■woman's    (see  also  Breast  Milk),  75 
analysis  of,   78 

comparative,  80,  83 
apparatus    for    examination    of,    79, 

81 
colostrum  in,   74 
comjx)sition  of,   78 
deterioration  of,   104 
examination  of,   microscopical,   81 
enzymes,   diastatic  in,  S2 
fat  in,  to  decrease,  104 
to  increase,  104 


934 


INDEX. 


^lilk.   "woman's,    immunity   confevi'ed   b\'. 
82,   483,   530 
method   of   changing   ingredients   in, 

104 
to   increase  quantity  of,   88,   96 
to   preserve,   S3 
proteins  in,   104 
reaccion  of,  82 
scanty,  87 

specific  gravity  of,  79 
specimen  for  examination,   SO 

how  to  procure,  80 
variations  in,  101 
Milk   substitutes,   cereal,    185 
humanized,    192 
Lahmann's   vegetable,    178 
mammala,    190 
Milk-sugar  or  lactose,  136 
Milk-test,  Babcock's,  133 
Mineral  salts  in  milk,  141 
Mixed  feeding,   87,   107 

additional  foods  during  the  nursing- 
period,  91 
Mobius'sche  kernschwund   (see  also  Pleu- 

roplegia),    800 
Modified  small-pox   (see  also  Varioloid), 

642 
Monarthritis,    368 

in  gonorrhoea!  vaginitis,   368 
Mongolian  idiocy,   807 
Monoplegia,   736 

Morbilli    (see  also  Measles),  584 
Morbus  coxarius,  861 
]\Iorbus  maculosus  Werlhofii,  706 
Mortality,    in    cerebro-spinal    meningitis. 
784 
in  consumption,  492 
in    diphtheria,    503 
in   measles   and   complications,    590 
in  small-pox,  638 
of  babies  raised  in  incubators,  28 
Morton's  fluid,  778 
Mosite    in    diabetes    insipidus,    383 
Mosquera's  beef  meal.  195 

beef  jelly,  196 
Motor   function   of   the   stomach,    876 
Mouth    breathing,    a    symptom    of    ade- 
noids,  411,   412 
of  enlarged  tonsils,  408 
Mouth,  condylomata  of,  in  syphilis,  676 
diseases  of,  205 

haemorrhage   from,   in   syphilis,    675 
hygiene  of,   17 
in  adenoid  vegetations,  411 
in  angina  Ludovici,  216 
in  Bednar's   aphthse,   208 
in  stomatitis  aphthosa,  207 
in   stomatitis   catarrhalis,   206 
in  stomatitis  mycosa,  208 
Movable   spleen,  352 

IMucous  membrane,   conjunctival,  in  gas- 
tro-duodenitis,    228 
of  mouth,  at  birth,  65 

in  measles,  586 
of  pharynx,  in  scarlet  fever,  608 


^Mucous  membrane,  of  stomach,  65 
in  gastric  catarrh,  219 
of  trachea  and  bronchi,  in  broncho- 
jmeumonia,  430 
Mucus   disease,   276 

in  stools,  242 
Muguet     (see    also    Stomatitis    Mvcosa), 

208 
Multiple  neuritis,  751 

treatment,  753 
Mumps,   716 

complications,  717 
diagnosis,  717 
isolation,  718 
period  of  incubation,   716 
symptoms,   716 
treatment,   717 
Murmurs,  330 
antemic,    331 
cardiac,  328,   330 
cerebral  blowing,   333 
]\Iurmur5,   diastolic,   331 
pericardial,    332 
systolic,  330 

in    chlorosis,    696 
venous,   332 

in  chlorosis,  696 
vesicular,   in  bronchial   asthma,   428 
Muscle  education,  812 
Muscles,    atrophy   of,    in   acute   mvelitis. 
764 
in  poliomyelitis,  770 
transplantation   of,    774 
fatty   infiltration   of,    in   pseudo-hyper- 

trophie   paralysis,    801 
intestinal,  74 

Avasting  of,  in  scurvy,   306 
Muscular  atrophy,  in  acute  myelitis,  764 
in   poliomyelitis,    770,    774 
in      pseudo-hvpertrophic      paralvsis, 
801 
rheumatism,   703 
spasms,  in  rachitis,  312 
]Mustard  foot  bath,  597 

in   convulsions,   741 
plasters,   897 
Myalgia,   703 
Myelitis,  acute,  764 

chronic,   766 
Myelocytes,   685 
in  diphtheria,  685 
in  leukaemia,  694 
in  pneumonia,   685 
in  svphilis,  685 
Myocarditis,    343 

complicating  diphtheria,   523 
treatment,   344 
IMyxcedema    (see  also   Cretinism^,   719 
^lyxoedematous  idiocy,   719 

Nrevus,  836 

Nails,   in   secondary   ansemia,    692 

in   syphilis,   675 
Nasal  "catarrh,   391 

a  symj)tom  of  measles,  390 


INDEX. 


935 


Xasnl    ontjirrli,   a    HViniitfun    of   svpliilis, 
075 
fausiiip  otitis,  IJOl 
(liplitlicria,  518 
(loiicliinp,  :!04,  (527 
syriiif^f,   .'iD.'J 
Naso-phannRcal   calarrli,  394 

in  sypliilis,  075 
Kavel,   dangers   in   handling,   35 

management  of,  17 
Necrosis  of  liver,  in  malarial   fever,  GOO 
of       jaw-bone,       following      stomatitis 
gangra'nosa,   211 
Nock,    in   cretinism,    710 

rigidity  of,   in   typhoid,   050 
stiff,    in    torticollis,    704 
Neonatorum    (see   New-born    Infant). 
haimoglol)inuria,  40 
icterus,  52 

urine  in,  878 
mastitis,  54 
ophthalmia,   821 
pemphigus,    50 
sclerema,  53 
Neo-salvarsan  in  treatment  of  noma,  214 
in  treatment  of  scarlet  fever,  032 
iilcero-mend)ranous    tonsillitis,    400 
Nephritis,  acute,  370 

as  a  coni])lieation,  372 

blood   in,   371 

complicating   diphtheria.    525 

influenza,  399 
urine   in,   371,   372,   879 
acute  glomerulo-,  370 
catarrhal,   in   scarlet  fever,   614,  620 
chronic     interstitial,     from     increased 

urinarv    pressure,   377 
post-searlaiinal,  015,  620 
secondary,  373 
Nerve,       pneumogastric,      in      dyspeptic 

asthma,  230 
Nerves,   in   multiple  neuritis,   751 

vasomotor,   causing  asthmatic  attacks, 
428 
Nervous      impressions,      effect      of,      on 

woman's   milk,   88 
Nervous  system,  diseases  of,  733 
hygiene  of,  23 
in   typhoid,   050 
Nestle's  food,   183 

analysis   of,    184 
Nettle  rash    (see  also  Urticaria),   830 
Neuralgia,    interstitial,   273 

complicating  variola,  042 
Neuritis,   multiple,   751 

complicating  influenza,   399 
treatment,   753 
peripheral,  751 
New-born,  abnormalities  of,  57 
acute  fatty  degeneration   of,  41 
asphyxia  of,  45 
bleeding  in,   670 
l^uhl's  disease,  41 
diphtheria   in,   35 
erysipelas   in,   55 


Newlxjrn,   Irafdin-  in,  43 

hicmoglobinuria    in.   40 

hajmorrhage,    ga-lro  intestinal,    in,    40 
into  adrenal  gl.ui  I-",  732 
umbilical,  35,  40 

ichthyosis  of,  50 

icterus  of,  53 

inflation  of  the  lungs  in,   4  7 

malformations  of,   57 

mastitis  in,  54 

paralysis  of,  43,  802 

pemphigus  in,  56 

peritonitis  in,  55. 

sclerema   in,   53 

syphilis   in,   072 

tuberculosis   in,   55,   673 

tvphoid  in,  047 
Night  cough,  421 

Night-sweats,    in    tuberculosis,    498  • 
Night-terrors     (see    also    Pavor    Noctur- 

nus),  753 
Nipple,   anticolic,    151,    153 

harelip,  58 

management  of  woman's,  92 

sterilizer,    153 
Nipple-shield,  93 
Nitrous  oxide  and  ether,  890 
Nodding-spasm,  743 
Nodes,    lymph     (see    Lymph    Nodes). 
Nodules,      subcutaneous      tendinous,      in 
rheumatism,  700 

tubercular,   779,   780 
Noguchi's  butvric-acid  test  for   syphilis, 

073 
Noma  (see  also  Stomatitis  Gangraenosa), 
210 

in  scarlet  fever,  632 
Nose,     discharge     from,     in     diphtheria, 
512 

diseases  of,   391 

foreign  bodies   in,   402 

haemorrhage     from,     in     exophthalmic 
goiter,   731 
in  syphilis,   675 

in   adenoid  vegetations,   411 

in  cretinism,   719 

picking  of,   290 
Nose-bleed      (see     also     Epistaxis),      in 
diphtheria,   524 

in  syphilis,   675 
Novocaine  as  local  anaesthetic,  892 
Nurse    (see  also  Wet-nurse),  22 
Nurserv,   furniture  in,  22 

light  of,  22 

location  of,  21 

method  of  heating,  22 

ventilation,  21 
Nursing    (see   also   Feeding),    84 

length  of  time  for,  87 

schedule  for,  84 
Nursing  bottles,   150 

care  of,   151 
Nutrient  enemata   (see  Rectal   Feeding). 
Nutrients   and   stimulants,    198 
Nutrition,   65 


936 


INDEX. 


Xiitrition.    impiopov.    298 

Nutritional  disturbance,   168 

Nutritive    tonics,    chemical    analysis    of, 

197 
Nutritive  value  of  eggs,   199 
Nvlander's  test  for  sugar  in  urine,  SS5 
Nystagmus,    complicating    spasmus    nu- 
tans.   7J:3 

in  hereditary  ataxy,  767 

Oatmeal  bath,   19 
in  eczema,  828 

water,   869 
Obliteration    of    the    bile-duets,    congeni- 
tal,  37 
Obstetrical  paralysis,   43 
Obstipation,  299  ' 

0'Dwyer"s  method  of   intubation,   547 
CEdema  in  angina   Ludovici,  216 
in  erysipelas,  660 
in  variola.  624 

of  ankle,  696 

of  cheek,  in  stomatitis  gangrjenosa,  211 

of   eyelids,    in   thrombosis    of   cerebral 
sinuses,   818 

of  feet,   in  myelitis,   765 

of  glottis,   in   scarlet  fever,   631 

of  lars-nx,   617 

of  lips,  in  myelitis,   765 

of  pia  mater,   617 

of  scalp,  818 
CEsophagitis,  acute,  217 

chronic  or  diplitheritic,  217 
(Esophagus,   foreign   bodies   in,   218 
Oigophony,  438,  440 
Oil,  enema,  in  acute  peritonitis,  355 

internally  in  chronic  constipation,  269 
Oiled-silk    jacket     (see    also    Pneumonia 
Jacket),  477 
how  to  make,  435 
Omphalitis,  diphtheritic,  35,  512 

septic,  36 
Omphalomesenteric  duct,  36 
Onanism    (see  also  ilasturbation),  754 
Ophthalmia,   granular,   822 

neonatorum,   821 

pneumococcus,  820 

purulent,  821 
Ophthalmo-tuberculin   reaction,   496 
Opisthotonos,   hysterical,   749 

in  meningitis,  786 
Orchitis,   366 

in  mumps,   717 
Orthostatic   albuminuria,    381 
Osteitis,  infectious,  866 

of  the  femur,  864 

of   the  tibia,   864 
Osteoclasis  in  rachitis,  320 
Osteomyelitis  (see  also  Arthritis,  Acute), 

866 
Osteotomy   in   rachitis,    320 
Otitis,  complicating  diphtheria,   523 

complicating   influenza,    399 

complicating  measles,  594 

complicating  rhinitis,  391 


Otitis,    complicating    scarlet    fever,    610, 
624 
complicating  typhoid,  654 
complicating  variola,   642 
Otitis  media,  acute  catarrhal,   812 
symptoms,   813 
treatment,   814 
Oxygen,  in  dyspnoea  and  cyanosis,  476 
in  piilmonary  stenosis,  334 
in   resuscitation,   48 
Oxyuris  vermicularis,  292 
Ozsena,  a  sequela  to  scarlet  fever,  622 
Ozonic  ether  test  for  pus  in  urine,  886 

Pachymeningitis,    acute,    794 
chronic,  794 
hfcmorrhagic,   794 
non-hoemorrhagic,    794 
Pack,  cold,  51S 

hot,   626 
Palate,  cleft,  58 

in   Bednar's   aphthse,    208 
in   measles,   585 
in  purpura  htemorrhagica,  706 
in   rubella,   578 

paralysis  of,  in  diphtheria,  526 
Palpation   of   the  liver,   346 

of  the  spleen,  352 
Palsy,  Erb's    (see  also  Paralysis),  774 

acute  spinal,  from  acute  cerebral,  770 
Paludal  fever   (see  also  Malarial  Fever), 

662 
Pancreas,  diseases  of,  353 
function   of,   353 
in   syphilis,   675 
position  of,    353 
Pancreatic  juice,   65 
Panopepton,    196 

Panophthalmitis,    in    meningitis,    786 
Papillomata,   847 
Paracentesis,  in   otitis,  628 
Paralysis,  following  pertussis,  457 
in  hereditary  ataxA-,  767 
in  multiple  neuritis,  752 
in   Pott's   disease,   851 
in    thrombosis    of    cerebral    sinuses, 

818 
of  vocal  cords,  following  intubation, 
567 
Bell's,  802 
cerebral,   795 

acquired  after   labor,   796 
diagnosis,    797 

differential,  from  infantile  spinal, 
799 
occurring  during  labor,  796 
of  intra-uterine  onset,  796 
facial,  802 

following  mastoid  operation,   817 

retro-pharyngeal  abscess,   817 
in  the  new-born,  802 
infantile   spinal,  768 
diagnosis,   770 

from   cerebral   paralysis,  799 
micro-organism  causing,  768 


INDEX. 


937 


I'arulyMiK.  inrmit il<>,  jdiMioIoffy,  TOO 
Byni[)tomH,  770 

fiicpanilytif,  770 
trf(itrncnt,"772 

rniiHcIc  I'diication,   772 
poHt  (liplitlicTilif,    r,2r»,    540 
fri'qiifncv  of,  520 
of  l>lu<l(i'f!r,   520 
of   r'x(  rctnidcH,  527 
of   paliiU',   520 
of    rectum,    520 
of  trunk,  520 
I'ara}))iiniOHiK,  .'{04 
Paraplegia     (»«'«    aho     I'aralyHh,     fVrc 

bral),  705 
Parasitic  Hl/mmtiliH    (hoc  uIko  RtomatitiH 

MycoHa),  208 
ParolitiH,  Hpf<'ifi<;   (Hen  alno  MiiiiipM),  710 
l'aHl(iiri/.fi(iiin  of  cowh'   milk,    157,  H72 
PaU'llar    reOexcH,    in    c'ereltriil    jiaralyHis, 
797 
in  diplitlieria,  514 
in  nieniii^^itiH,   780 
in  pseiKloliypertropIiic  fiiiralyHiH,  802 
Patent  foodn,    181 
I'avor  noftiirnuH,  753 
I'cdifMiloHiH,   8.'{:{ 
Peliowis  rlifiimatifii,  700 
IVllaKra,  255 
PcIvIh,   in   f'ongenital   (liniofiition  of   liipw, 

803 
IVmpliif^iiH,  elironie,  830 
Pempliij^iiK,    in    Hypliilin,    075 

nf'onatoriim,   50 
PendulfMiH    hclly,    in    racliitiw,    310 
PepHin,  05 

funilion  of,  00,  07 
in   (fa«trie  font^-ntu,   870 
Pe[)to{;enic  milk    [lowdcr,   102 
Peplone,    in   ^!n'*^til•  eonfenlH,   870 
]'<'[ilotii/<'d    milk,    873 
P(?r('enla;|e   feeding;,    170 
PemiBHion,   of   I  he    liin;,'K,   421 
of  the  Hkull,  733 
resonance,    424 
Pericardial  mnrmurH,  332 
PcriearditiH,   330 

eom[)lieatinp  diplitlierlo,   523 
f'unipliealinj^    rlioiimatiKtn,    054 
coiiiplicaiiii;^   ly[)lioirl,    701 
elironii',    with    jidiii-HionH,    342 
Pericafdinm.    iiKpirafion    of,    341 

tnbcrciiloHiM   of,   342 
Pcrinej)liriiiH,   374 

dinjfnosiH  from  hip  joint  diwuKe,  375 
Bimtilatin;;   Pott'n   dineaBe,  375 
Hitnulatinf?  Hciatica,   375 
Perineum,    in    impcrforato  anim,   03 
PerioHtiti«,   conijilicalitig  HtoniatitiH  {?an 
{(rfcnoKa,    211 
in  Hy[»hiliH,  077 
Peripheral    neuritis     (sec;    also    Mullijile 

Ncuritin),    751 
Peritoneum,  diHcaHCH  of,  304 
Peritonitin,  acute,  354 


I'erilonitiH,   in  ni...   ;iiw>iii>M   due   to.   359 
eom|»licatitiK    i  hentnatimn,    700 
complicating   t\pli<,ir|,   fl54 
chronic,   355 
OlirinouH,    354 
in   I  he   new  Inirn,  fiS 
non  tuhcrculoMM,    355 
purulent,   354 
McrouM,  354 
tul»cr(MilouH,  350 
Perilonsilhir  ahnceuM,  400 

rexenihlin^^  diphtheria,  522 
Peril  A'phlitin      (nee     also     Ap()endieitiM) , 
'  278 
(uhen-uloiiH,  480 
I'erniciouH  aniemiii,  002 
I'erHpira)  ic)n    (nee   alw)   Kweating),    12 
PertUHMiH,   455 

complement  deviation  U'nt,  450 
comjdicaf ioiiM,  457 
dia^nohiH,  450 
«e«|ucl!i',  XuhcrculowiH,   4H0 
trciitment,  458 
vaccine,  452 
Pclechia,   in   liiemo|ihilia,  710 

in  |>ur]uira,  705 
I'eycr'M    p;itchcH,   72 
in  typhoid,  040 
Ph:nyn;;cjil    cat;irrli,    (au»-iii;/;    hpa>«modi<' 

cmup,  4  17 
rh.iryn^itin,   415 

in    inttuen/.'!,   300 
Pharynx,    in    local    diphtheria,    512 
in    mycoMii,  208 
in    Kcarlet   fever,   004 
in    Hcptic   diphtheria,    512 
in  Klomalitis  aphthoxa,  207 
rhimosis,   303 

rhlc;,'nionouH   tonHilliiiH,   400 
i'hloro;^lucin     lent    for    formaldi-ln  i|i.     in 

milk,    no 
IMilycfi-niilar   <onjuin(  iv  i(  is     HVCi 
I'lKiKpJioruH,    141 

in   rachitiH,  310 
l'liot/»phohia,     in     cen-hro  spinal      menin 
j<itiH,  780 
in    influen/.a,   300 
ill    meaMlcH,   585 
I'hlhiKin     (is"e     .iIko     I'uliiion.H  \'     'I'uhcr 
•■uloHi«),   408 
pulmonis,   mortality   in,  401 
I'hyiiicil   cx.imin.ition,  of   heart,   327 

of   lun;,'n,   423 
I'hyHicol  exer«'i«e,  22 

KiffiiH,   in  empyema,  440 

in   lohar  pneunKuiia,  420,  400,  472 
in    pleiiriny   with   efTusion,   438 
I'ia   maf/'r,   hlotid  veHneU  of,   730 

cloHiire  of,    in    hydrocephaluH,   736 
in    tubercular    iiieningitiM,    779 
I'if^con  brcaHt    (mcc  also  Prominent  Sti'r- 
num),  01 
in   ra<hiliK,  310,  312 
Pigmentary   na?viiH,   736 
Pink  eye,  820 


938 


INDEX. 


Pinworms.  292 
Plasmodium  malarise,  662 
Plasmon,    195 
Pleura,    diseases   of,   423 
effusion  into,  43 S 
swollen,  in  dry  pleurisy,  436 
Pleurisy,  435 

complicating  diphtheria,   435 
complicating  rheumatism,   700 
dry,  436 
purulent,    439 
with  effusion,  437 
diagnosis,   438 

exploratory   puncture,    438 
symptoms,   438 
treatment,  438 
Pleuritis,  exudativa,  437 
Pleurodynia,  703 
Pleuroplegia,  800 
Pleuropneumonia,  464 
Pleurothotonus,  in  pericarditis,  340 
Pneumococeus.      in      broncho-pneumonia, 
430 
in  empyema,   440 
in   follicular   tonsillitis,   405 
in  measles.   594 
in  meningitis,  784 
in   perinephritis,   374 
in  pleurisy  with  effusion,  437 
ophthalmia,    820 

vaccine  treatment,  453 
Pneumo-gastric       disturbance,       causing 

asthmatic  attacks,  236,  428 
Pneumonia    ( see   Broncho-pneumonia ) . 
abortive,  462 
catarrhal,   464 
cerebral,   464 
croupous,  460 
gastric,  464 
iabar,   460 

bacteriology,  462 
course,  465 
crisis,  467 
diagnosis,   472 
etiology,   460 
isolation,   472 
pathology,   462 
relapse,  472 
symptoms,  465 
treatment,  473 
vaccine,  454 
migrans,  464 
pleuro-,   464 
tuberculous,   477,   479 
wandering,  464 
Pneumonia  jacket,  434 
Pneumothorax,   artificial,   444 
Pock   in  varicella,    633 
Poikilocytosis,  in  syphilis,  685 
Poisons    (see  Toxins). 

causing  toxic  multiple  neuritis,   752 
elimination  of,  245 
Poliomyelitis     (see    also    Paralysis,    In- 
fantile Spinal),  768 


Poliomyelitis  acute   anterior,   from   post- 
diphtheritic paralysis,  527 
Polvarthritis     (see     also    Rheumatism), 

698  - 
Polydipsia    (see  Thirst,   Excessive). 
Polvmorphonuclear    cells,    in    ervsipelas, 
6S4 
in  diphtheria,  684 
in  pneumonia,   684 
in   scarlet  fever,  684 
Polyneuritis     (see    also    Multiple    Neu- 
ritis), 751 
Polynuclear    leucocvtes.    increase    of.    in 
pus,  281      .  '       ' 
in   infectious   diseases,   684 
Polypus,  rectal,  689 

umbilical,  36 
Polyuria,   383 

in   diabetes   mellitus,   384 
Porencephaly,   778 
Potassium  salts  in  milk,  142 
Post-diphtheritic  paralysis,  526 
Post-operative    palsy     (see    also    Facial 

Paralysis),  802 
Pot-bellv    in    rachitis    (see    also    Pendu- 
lous Belly),  316 
Pott's  disease,   848 
complications   851 
differential    diagnosis    from    rickets, 

321 
pathology,  849 
symptoms,   850 
treatment,  854 
Poultices,    flaxseed,    in    retro-pharyngeal 
abscess,  416 
in  tonsillitis,  404 
how  to  make,  896 
ginger.   897 
Powder,  dusting,  IS,  635 
Precordia,   prominence  of,   328 
Predigested  milk,  873 
Pregnancv.     effect    of,     on    nursing    in- 
fants, 32 
Premature  infants,  26 

method  of  feeding,   30 
Prepuce,   adherent,   363 

tight,  causing  enuresis,  389 
masturbation,   754 
Prescriptions  for  various  diseases,  900 
Pretubercular   anaemia,  493 
Priapism,   in  phimosis,  363 
Prickly  heat,   833 
Procrisis,  in  pneumonia,  467 
Proctitis,   croupous,   295 
simple,  catarrhal,  294 
ulcerative,  295 
Prognosis,  in  disease,  14 
Prolapse  of  rectum,  296 

in  diseases  of  the  bladder,  379,  386 
of  the  intestines,  262 
Prominent   sternum,   61 
Propeptone  in  gastric  contents.  876 
Prophylaxis  in  diphtheria,  528 
Proprietary   infant  foods,    181 
Protein,  function  of,  in  diet,   137 


INDEX. 


939 


I'nifciii   in  cows'   milk,   138 

in   excess,   causing  colic,   274 
in  woman's  milk,   103,   138 
to  increase,    104 
Protrusion  of  oars,  60 
Pseudo-appendicitis,   282 
Pseudo-diphtheria,    500 
Pscu(lo-hypertro])hic   paralysis,   801 
Pseudo-leukiemic  ana-niia,  094 
blood  in,  695 
S[)leen  in,  095 
Pseudo-paralysis,   in  scurvy,  303 

in  syphilis,  080 
Pseudo-pertussis,    422 
Psoriasis,  832 
Ptosis  in  thrombosis  of  cerebral  sinuses, 

818 
Ptyalin,  function  of,  67 
Pulmonary     artery,     thrombosis     of,     in 
diplitheria,  524 
gangrene,  482 
gymnastics,  498 
in  empyema,  443 
in    tuberculosis,    498 
stenosis,  333 
tuberculosis,    479 
Pulmotor,  Dragcr,  48 
Pulse,  in  diagnosis,   10,  330 
Pulsus   paradoxus,    330 
Pump,  breast,  93,  94 
Pupils,  as  diagnostic  aid,   12 

in   cerebro-spinal   meningitis,   786 
in  chorea,  746 
in  insolation,  240 
in  myelitis,  764 
in    pachymeningitis,    794 
Purpura,   405 

complicating   rheumatism,    700 
diagnosis  from   scurvy,  706 
hemorrhagica,  706 
rjiouniatica,   706 
Purulent    ophthalmia,    868 
pleurisy,  439 
synovitis,   acute,   866 
Pus    corpuscles    in    urine    from    case    of 
scarlatinal   nephritis,   616 
testsi  for,  in  urine,  SS6 
Pjajmia,   complicating   measles,    595 
typhoid.  654 
in  acute  nephritis,  866 
Pyelitis,   376 

in  gonorrhoeal  infection,  368 
Pyclo-nephritis    (sec   also   Pyelitis),    376 
Pyloric  obstruction,  224 
diagnostic  aid,  224 
symptoms,  224 
Pylorus,  spasm  of,  224 
Pyuria,   381 

in  colicystitis.  3S6 
in  pyelitis,  377 

Quartan    intermittent    fever',    064 
Quincke's  lumbar  puncture,  787 
Quinsy,  406 
Quotidian  intermittent  fever,   663 


Rabies,  vaccine  treatment,  453 
Rachitis,  307 
causes,  3 1 1 

lack  of  vitamines,  144 
deformities,   319 
diagnosis,  316 

differential,  from  Potfb  disease,  321 
diet  in,  318 

laryngeal  stenosis   in,  563 
prognosis,  317 
symptoms,  311 
treatment,   318 
of  kyphosis,  319 
Ranula,  215 

Rashes    (see  Eruptions). 
Raw  milk,  128,  129,  131 
Raynaud's  disease,   841 
Reaction  of  degeneration,   737 
in   acute  myelitis,   764 
in   acute   poliomyelitis,   770 
in  multiple  neuritis,  752 
in    obstetrical   paralysis,    44 
Rectal,  feeding  in  bronchitis,  427 

in    cerebro-spinal    meningitis,    783 
injections     (see    Enemata    and    Irriga- 
tions). 
IKilyj)!  297 
Rectum,  congenital  absence  of,  64 
diseases  of,  294 
imperforate,   63 
malformations  of,  63 
protrusion  of,  296 
stimulation  by,  476 
Red    gum     (see    also    ^Miliaria    Rubra), 

843 
Reflex  cough,  422 
Reflexes,  in  acute  myelitis,  764 
in  cerebral  paralysis,  797 
in   spinal   paralysis,   770 
patellar,    in   cerebro-spinal    meningitis, 
786 
in   diphtheria,   514 
in  hereditary  ataxy,  768 
in   pachymeningitis,  795 
Regurgitation,    of    food    in    pyloric    ob- 
struction, 224 
nasal,  416,  522,  526 
Remittent     fever      (see     also     ilalarial 

Fever),   662 
Rennet,  action  of  milk  on,   139 

test  for.  in  gastric  contents,  876 
Resection  of  ribs,  442 
Resonance,    percussion,    424 

vocal,  424 
Respirations    (see   Breathing), 
artificial,  46 
asleep,  11 
awake,   1 1 

Cheyne-Stokes,     in    tuberculous    pneu- 
monia,  478 
in  bronchial   asthma,   428 
in  bronchitis.  426 
in   broncho-pneumonia,   431 
in  infancy,  431 
in   lobar   pneumonia,   466 


940 


INDEX. 


Respirations,    in    tubercular    meningitis, 
786 
wheezing,  428 
Respiratory  system,  diseases  of,  391 
Rest  treatment  in  chorea,  747 
Restlessness    at    night,    a    symptom    of 
worms,   291 
in  constipation,  268 
in  faulty  metabolism,  299 
in  gastroptosis,  232 
in  rachitis,   317 
Resuscitation  of  the  new-born,  46 
by  pulmotor,  48 
Byrd's  method,   46 
Retraction     of    head,     in     eerebro-spinal 
meningitis,  786 
in  epilepsy,  761 
in  influenza,  396 
Retro-cesophageal,  abscess,  217 
Retro-pharyngeal    abscess,    416 

complicating      cerebral      pneumonia, 
465 
lymphadenitis,    415 
Rhagades   of   anus   and   mouth   in   syph- 
ilis, 675,  680 
Rheumatic  torticollis,   705 
Rheumatism,   acute,   698 
bacteriology,  699 
complications,  700 
symptoms,   699 

subcutaneous     tendinous     nodules, 
700 
treatment,   701 
articular,  700 
chorea  in,  700 
following  tonsillitis,   699 
muscular,    703 
purpura  in,  700 
Rhinitis    (see  also  Nasal   Catarrh),   391 
Rhinolith,  402 
Rhino-pharynx,     method     of     examining 

for  adenoids,  412 
Rhythm,   424 
Ribemont's  tube  for  inflating  the  lungs, 

47 
Ribs,  beaded,   311,  312 

resection  of,  442 
Rice  water,  846 

Rickets    (see  also  Rachitis),   307 
Rimini    test   for    formaldehyde    in   milk, 

119 
Ringworm    ( see   also   Tinea   Tonsurans ) , 
837 
x-ray  treatment,  837 
Robert's  test  for  albumin  in  urine,  883 
Roentgen  rays  as  diagnostic  aid,   15 
Rotary   spasm   of   head    (see   also   Spas- 
mus Nutans),  743 
Rotheln   (see  also  Rubella),  577 
Round  Avorms,  290 
Rubella,  577 

complications,  582 
desquamation,  580 
diagnosis,  578 
eruption,  579 


Rubella  period  of  invasion,  578 

symptoms,   578 

treatment,  582 
Rubeola   (see  also  Measles),  584 
Rupture    ( see  Hernia ) . 

of  spleen,  in  malarial  fever,  666 

Sacral   tumor,   congenital,   62 

Saint   Vitus's   dance    (see   also    Chorea), 

744 
Salicylic-sulphur   paste,   829 
Saline    solution,    for    colonic    flushings, 
632 
in  erysipelas,  661 
cold,   in  typhoid,   655 
subcutaneous  injections  of,  626 
Saliva,  action  of,  on  bacteria,  66 
in    stomatitis   gangrsenosa,   210 
secretions  of,  at  birth,  65 
Salt-free    diet    in    scarlet    fever    and   ne- 
phritis,  624 
Salts  in  milk,   141 

Sarcoma,  spindle-cell,  of  the  thorax,  842 
Scabies,  841 

Scalp,      fatty     growtlis     of      (see     also 
Lipoma),  846 
in   caput   succedaneum,   62 
ring-Avorm  of,  837 
seborrhcea  of,  835 
Scarlatina    (see  Scarlet  Fever), 
papulosa,  607 
post-operative,  622 
sine  angina,   607 
sine  exanthemata,   606 
sine  febre,  607 
variegata,  607 
Scarlet  fever,   599 
bacteriology,  60O 
blood  in,  602 
complications,    608,    611 
diagnosis,   617 

from  variola,  641 
hsemorrhagic,    606 
inclusion    bodies    in    blood    of,    601, 

602 
incubation   stage,   600 
isolation,  618 
rash,   604,   617 
septic,   605 
symptoms,  604 
treatment,  618 

serum,  628 
vulvo-vaginitis  following,  622 
Schick  reaction,   520 
Schonlein's   disease,    706 
Sciatica,   375 
Sclerema  neonatorum,   53 
Scoliosis,  855 
Scorbutus,   301 

Scrofula   (see  also  Tubercular  Adenitis), 
714 
lesions  of,  681 

resembling   tuberculosis,   484 
Scurvy,  301 

caused  by  lack  of  vitamines,  144 


INDEX. 


941 


Scurvy,    caiisod    by    prolonged    sterilized 
Jiiilk  feeding,   155 
diagnosis,  .303,  306 
etiology,  301 
pathology,  302 
symptoms,  303 
treatment,   300 
Seborrlicea,  835 
Secondary   anasmia,    G92 
Seiler's  solution,  393 
Senses,  development  of,  2 
Sensitive  skin,  19 
Septic  diphtheria,  512 

nephritis,    complicating    scarlet    fever, 

615 
omphalitis,   36 
Serum   injection,   intravenous  method  of, 
788 
in   gastro-intestinal   hemorrhage,   42 
in  premature  infants,   33 
in  tubercular  peritonitis,   392 
test  for   typhoid,   648 
treatment  of  diphtheria,   534 
of   dysentery,   266 
of  erj'sipelas,   661  • 

of  meningitis,   792 
of  poliomyelitis,  772 
of  scarlet  fever,   626 
of  tetanus,   758 
Serum  treatment  of  typhoid,  654 
Shingles    (see   also   Herpes   Zoster),    831 
Shock,   anaphylactic,   518 
in  intussusception,  288 
in  typhoid,   655 
Shoe,  proper,  20 
Shoulders,  in  lateral  curvature  of  spine, 

857 
Sigmoid   flexure,   73 

abnormalities  of,   266,  267 
Simple    catarrhal    proctitis,    294 
Singultus,   in  pericarditis,   340 

in  typhoid,  654 
Sinus  thrombosis,  818 
Sitting,  when  established,  2 
Skin,  cachectic,  in  syphilis,   676 
diseases  of,   826 
blood  in,  686 
in  Addison's  disease,  732 
in    chlorosis,    696 
in  cretinism,  719 
in   eczema,,    827 
in  faulty  metabolism,  298 
in  fcetal  ichthyosis,  50 
in  gastro-duodenitis,   228 
in  meningitis,  787 
in  Mongolian  idiocy,  807 
in  multiple  neuritis,  752 
in   pellagra,   255 

in   pseudo-leuka?mic  ansEmia,   695 
in   secondarj'^   an.iemia,    692 
in  Winckel's  disease,  40 
sensitive,  19 
Skull,   in   epilepsy,   760 
in   hydrocephalus,   776 
in   rachitis,   308,   310 


Skull,   pcrcusfsion  of,  773 
Sleep,  as  diagnostic  aid,   14 

examination  tluring,   9 
Smallpox    (see  also  Variola),   638 
Smegma,  363,  364 
Sneezing,    in   measles,   585 

in   rubella,   578 
Sniffles    (see   Coryza). 

in   syphilis,   675 
Snoring,   a   symptom   of   adenoids,    412 
of  hypertrophied  tonsils,   408 
of  retropharyngeal   abscess,   416 
Soap,  use  of,  19 
Sodium  salts  in  milk,  142 
Somatose,    194 

Soor    (see  also  Stoiuatitis  Mycosa),  208 
Sore  nipples,   92 
Soson,   195 
Spasm,  clonic,  761 

epileptic,   760 

muscular,  in  rachitis,  312 

of  bronchial  muscles,  428 

of  glottis,   428 

of  larynx,  428 
in  rachitis,  312 

of   pylorus,   224 
Spasmodic   cough,   422 

croup,  417 

laryngitis,   417 
treatment,  418 
Spasmophilia,  756 

in  rachitis,  316 
Spasmus   nutans,    743 
Spastic   diplegia,    795 
Specific  gravity  of  blood,  at  birth,  684 
of  milk,  76,  77 
of  urine,   877,  881 
Speech  defects,  744 

late    (see   also  Alalia   idiopathica),    3, 
806 

sudden  loss  of,  4 
Spina  bifida,   766,   846 
Spinal  brace,  859 

cord,  in  acute  myelitis,  764 
in  chronic  myelitis,  765 
in  tubercular  meningitis,  765 
malformations    of,    766 

curvature,  855 
in  rachitis,  319 

fluid,  673 

in  meningitis,  786 
in  pellagra,  255 

paralysis,  768 
Spine,    abscess   of,    851 

diseases   of,    848 

in  Pott's  disease,  848 

in  rachitis,  319 

lateral  curvature  of,   855 

paralysis  of,   852 
Spirochoete  pallida,  674 
Spleen,   diseases  of,  352 

enlargement  of,   352 

in  acute  tuberculosis,  493 

in  aniemia,   091 

in   chlorosis,    696 


94-3 


INDEX. 


Spleen,  in  leuksemiaj  693 

in  malaria,   667 

in   malignant  endocarditis,   339 

in  multiple  neuritis,  752 

in  pseudo-leuksemic   anaemia,   695 

in  rachitis,  307 

in  typhoid,   650 

movable,  352 

palpation  of,  352 

rupture  of,  666 

■wandering,    352 
Splenic   anaemia,   691 

Sponge  baths,  to  reduce  temperature,  476 
Spontaneous  haemorrhage,  39 
Spotted  fever    (see  also  Meningitis,  Epi- 
demic), 784 
Sprav,  nasal,  393,  394 

throat,  392,  407 
Spray  bath,  cold,  in  hysteria,  751 
Sprue   (see  also  Stomatitis  Mycosa),  208 
Spurious,  cephalhaematoma,  62 

hydrocephalus,  308,  310 
Sputum    (see  Expectoration). 

disinfection   of,    894 

in  bronchitis,   426 

in  tuberculosis,   495 

in  typhoid,   656 

test  for  tubercle  bacilli  in,  888 
Square  cranium  in  rachitis,  308,  312 
Squinting,   12 
Stammering,  744 
Staphylococci,  in  bronchitis,  425 

in   broncho-pneumonia,   430 

in  diphtheria,  504 

in  empyema,  440 

in  erysipelas,   658 

in  follieiilar  tonsillitis,  405 

in  measles,  584 

in  perinephritis,  584 

in  pleurisy  with  effusion,  437 
Starch,   145' 
Statistics    (see  Mortality). 

diphtheria,   bacteria    in,    548 
immunity  from,   533 

measles  with  ear  complications,  595 

mothers,  percentage  of,  able  to  nurse, 
97 
unable  to  nurse,  100 
Status  Ivmphaticus,   711 
Steak  ju'ice,  200 

Steam   inhalations    (see  Inhalations). 
Steapsin  ferment  test,  225 
Stenosis,  congenital,  of  lai-ynx,  60 

hypertrophic,  of  the  pylorus,  224 

laryngeal,     following    intubation     and 
decubitus,  569 

in  diphtheria,  512,  535,  542 

in    retro-pbaryngeal   abscess,   416 

intubation  in,  553 

pulmonary,  3.33 

recvirring,   561 

spasmodic,   224 

subglottic,  in  syphilis,  554 
Stercoraceous  vomiting    (see   also   Faecal 
Vomiting),   281 


Sterilization  of  milk,  152 

causing  constipation,   155 
chemical    changes   produced  by,    128 
scurvy  caused  by,   303 
Sterno-mastoid,  haematoma  of,  61 
Sternum,  61 

in  scoliosis,  857 
Stethoscopes,   328 
Stimulant,  coffee  as  a,  202 
whisky  as  a,  203,  476 
Stock  vaccines,  451 
Stomach,  acids  in,  66 
anatomy  of,   65 
capacity  of,   63,  69,  70 
diseases  of,  65 
haemorrhage  from,  731 
infantile,  65 
low  position  of,  232 
motor  function  of,  876 
mucous  membrane  of,  65 
physiology  of,   65 
translumi nation   of,    231 
ulcer    of,   234 

unorganized    ferments    in,    66 
Stomach  washing,  72 

in  acute  gastric  catarrh,  207 
in  chronic  gastritis,  230 
technique  of,  72 
Stomatitis,   205 
aphthosa,  206 
catarrhalis,  205 
croupous  or  diphtheritic,  209 
gangraenosa,  210 
mycosa,  208 
syphilitic,  210 
Stone  in  the  bladder,  386 
Stools,   infant,   237 

bloody,  242,  254,  286 

in  Henoch's  purpura.   708 
in  intussusception,  286 
in  syphilis,  675 
brown,   242 
casein   in,   237,   240 
curds,  white,   in,   240 
diastatic  enzymes  in,  82 
disinfection  of,  894  , 

in  typhoid,  656 
dyspeptic,  243 
excess  of  fat  in,  242 
green,   224,   239 

in  derangement  of  liver,   347 
in   faulty   metabolism,   299 
in  gastro-duodenitis,  254,  288 
in    gastro-intestinal    haemorrhage, 

41 
in  scarlet  fever,   606 
in  typhoid,   649 
in   pyloric   stenosis,   224 
mucus,    242 
normal,   237 

of    buttermilk-fed    infant,    177 
of  nursling,  237 
scybalous,   243 
white  or  light  gray,  242 


INDEX. 


943 


Strabismus,     following     cerebral     paral- 
ysis, 707 
cerebrospinal    meningitis,    786 
pertussis,  457 
in   tubereular  meningitis,   780 
Streptococci,   in   acute  peritonitis,   ,']54 
in  broncliitis,  425 
in   bronclio-pneumonia,   436 
in   empyema,   440 
in  erysipelas,  658 
in  follicular  tonsillitis,  405,  452 
in   measles,   405 
in   meningitis,   787 
in   pcrine])lnitis,  374 
in  pleurisy  with   efl'iision,  437 
in   pseudo-diplitheria,   500 
smear  from  throat  exudate,  506 
stain  for,  889 
Strepto-diplococcus   in  scarlet   fever,   600 
Streptolytic     serum,     in     treatment     of 
scarlet  fever,  629 
in   tubercular  peritonitis,   358 
Strophulus   infantum    (see   also  IMiliaria 

Rubra),   834 
Stupe,  turpentine,  896 
Stuttering    (see   Speech  Defects). 
(Stye,  744,  825 
Subarachnoid  space,   fluid  in,   736 

haemorrhage  into,  736 
Subcutaneous  hfemorrhnge  in  scurvy,  303 
tendinous  nodules,  in  rheumatism,  700 
Submaxillary  glands,  in  diphtheria,  512, 
513 
in  scarlet  fever,  604,  613 
Subphrenic  abscess,  351 
Substitute  foods,   173 
Sucking,   65 
Sudamina,   834 

Sudden   death,   caused   by  careless   injec- 
tion  of   antitoxin,   534 
caused  by  enlarged  thymus,  711,  713 
in   diphtheria,    528,    553 
in  myocarditis,  344 
Suffocation   from  vomited   milk,   28 

reflex,  in   angina  Ludovici,   216 
Sugars,  135 

excess  of,  causing  colic,  273 
cane,  137 
in  urine   (see  Glycosuria). 

test  for,  885 
malt,   136 
milk,  136 
Sulphur  baths,  791 
Summer  diarrhoea,  262 
Sunlight  in  treatment,   of  chlorosis,   697 
of  peritonitis,  358 
of  scurvy,   307 
of  tuberculosis,   498 
Sunstroke,   246 
Superficial   gangrene,   840 
Supplementary   head,    62 
Suprarenal   capsules,   370 
Sutures,  separation  of.  in  hydrocephalus, 

776 
Sweating,  head,  in  rachitis,  222 


Sweating,    in    acute    tuberculosis,    498 

in  malarial  fever,  670 

in  very  .young  infanls,  12 
Symmetrical   gangrene,  841 
Symptoms  and  diagnosis   (s:c  also  Diag- 
nostic  S\igg(!stionbj ,   9 
Syncope   in   pericarditis,   340 
Synovitis,     complicating     scarlet      fever, 
614 

followed   bv'  knee-joint   disease,    868 

purulent,  866 
Syphilis,  672 

butyric-acid  test,   673 

congenital,   680 

diagnosis,   677 

ha>ninrrhagic,    675 

hereditary    (see  Inherited). 

inlieritedj   672 
Colles's  law,  673 
contagion   of,   673 

intubation  in.  554 

luetin   test,   678 

modes  of  infection,  672 

prognosis,  680 

spirochsete  pallida,   674 
refringens,   674 

stomatitis  in,  682 

symptoms,  674 
Syphilis,  symptoms,  bones,  674 
skin   lesions,   676 
teeth,  676,   679 

transmission  of,  680 

treatment,  680 

Wassermann  reaction   in,  678 
Syphilitic  stomatitis,  210,  682 

teeth,  676,   679 
Syringe,  nasal,  393 
Systolic  murmurs,  330 

Tache    cerebrale     in    tubercular     menin- 
gitis, 786 
Tachycardia,  330 

in  diphtheria,  527 

in  exophthalmic  goiter,   731 
Talipes,  congenital,  with  rachitis,  320 
Tapeworms,  289 

Tapping  the   abdomen   in   ascites,   360 
Tea,   204 
Teeth,  eruption  of,  7 

grinding  of,  a  symptom  of  worms,  290 

hygiene  of,  17 

in  adenoid  vegetations,  411 

in  cretinism.   719 

in  rachitis,  312 

in  stomatitis  gangrenosa,  208 

in  syphilis,  676,  679 
Teething    (see    Dentition). 
Temperature    (see   also    Fever),    11 

effect  of   sugar   feeding  on,    137 

how  to  reduce,  474 

in    distinguishing   the    still-torn    from 
the  dead,  46 

variations   in,  445 
Tender  nipples,  92 
Tenesmus,   in   colicystitis,   386 


944 


INDEX. 


Tenesmus,  in  dysentery,  252 

in  intussusception,  285 

in  vesical  calculi,   386 
Tertian,  intermittent  fever,  662 

double,    622 
Testicles,  in  hydrocele,  363 

in   orchitis,   complicating  mumps,    717 

tuberculosis  of,  486 

undescended,  365 
Tetanic    seizures    in    rachitis,    312 
Tetanus,  758 

Tetany    (see  also  Spasmophilia),   756 
Thermometer  bath,   19 
Thirst,    excessive,    in   diabetes    insipidus, 
383 
in  diabetes  mellitus,  385 
in  diarrhoea,  245 
in  gastric  catarrh,  219 
in  gastro-duodenitis,  226 
Thoracoplasty  in   chronic   empyema,   444 
Thorax,  depression  of,  in  rachitis,  312 
.    in  empyema,  441 

sarcoma  of,  842 
Threadworms,  292 
Throat,  as  diagnostic  aid,  13 

diseases   of,   291 

ice-bag,  427 

in  diphtheria,  520 

in  rubella,  578 

in  scarlet  fever,  604,  627 

spray,  407 
Thromboplastin  in  treatment  of  lisemor- 

rhages,  42,  415 
Thrombosis,  in  diphtheria,  511,  524 

in  gangrene,  839 

of  pulmonary  artery,  524 

sinus,    818 
Thrombokinase,     deficiency     of,     causing 

haemorrhage,  40 
Thrush     (see    also'    Stomatitis    Mycosa), 
208 

resembling  diphtheria,  520 
Thymic  asthma,  713 
Thymus,   711 

diseases  of,  712 

primary   tuberculosis   of,   486 
Thyroid,  abnormality  of,  732 

desiccated     extract    of,     in    cretinism, 
730 

implantation  of,  731 

in   exophthalmic   goiter,   731 

in  leukaemia,  693 
Thyroiditis,   acute,   732 
Tic,  745 
Tinea  tonsurans,  837 

versicolor,   832 
Tongue,  as   diagnostic  aid,   13 

bifid,  214 

epithelial  desquamation  of,  214 

hypertrophy  of,  214 

in   chorea,   746 

in   cretinism,   719 

in  diphtheria,  512 

in  gastritis,  229 

in  glossitis,   215 


Tongue,  in  measles,  585 
in  rubella,  578 
in  scarlet  fever,  604 
tubercular  infection  of,  486 
Tongue-tie,  59 
Tonics,   restorative,   625 

nutritive,   194 
Tonsillaris,  angina,  403 
Tonsils,   enlarged,   408 

causing  bronchial   asthma,   428 
indications    for    removal,    408 
predisposing    to    laryngeal    stenosis, 
561 
in  diphtheria,  512 
in  leukaemia,   693 
tuberculosis  of,  410 
Tonsillitis,  403 

bacteriology,  403 
sequelae,  chorea,   746 

rheumatism,   699 
significance  of,  404 
treatment,  404 
serum,  452 
croupous,  405 
follicular,  404,  522 
hypertrophic,  chronic,  407 
phlegmonous,   406 
ulcerative,  522 
ulcero-membranous,    405 
neO'Salvarsan  in,  406 
Tonsillotome,  Baginsky,  409 

Mackenzie,  409 
Tonsillotomy,   409 

bleeding   following,  ^  408,    409 
Torticollis,   704 

treatment,  705 
Toxaemia,   in  auto-intoxication,  285 

in  dysentery,   253 
Toxicosis,  299 

Toxin,   diphtheria,   effect   of,   on  nervous 
system  of  animals,  510 
in  scarlet  fever,   604,   606 
Toxins   ( see  Poisons ) . 
causing  convulsions,   739 
elimination  of,  538 
Trachea,  cannula,  silver,  575 
hard-rubber,  575 
stenosis  of,   546 
Tracheotomy,   in   laryngeal   stenosis,   574 
operation,  575 

after-treatment,   575 
in  syphilitic  subglottic  stenosis,  668 
Trachoma,   807 
Transfusion,  629 

in  haemorrhage  of  new-born,  42 
Translumination  of  stomach,  231,  232 
Traumatism,  causing  arthritis,  866 
aphthae,  17 
cerebral  abscess,  804 
epilepsy,   760 
joint  disease,  864 
Tropon,    195 

Trousseau's  sign  in  tetany,  750 
Truss,   in   umbilical  hernia,   289 
Trypsin  ferment  test,  226 


INDEX. 


945 


Tubercle   bacilli,    disseminated   by   cows, 
124 
in  tubercular  perinephritis,  375 
in  the  urine,   880 
stain  for,  in  sputum,  888 
transmission   of,   487 
Tubercular,  adenitis,  714 
empyema,  444 
hip-joint   disease,   861 
meningitis,  779 
peritonitis,   357 
Tuberculides,  49G 
Tuberculin,  injections,  499 
test  for  diagnosis,  300,  496 
cutaneous  reaction,  496 
ophthalmo  reaction,  497 
Tuberculosis,     following    cerebral    pneu- 
monia, 472 
chlorosis,   696 
empyema,  444 
scrofulosis,   484 
in  the  new-born,  55,  484 
manifestations  in  bladder,  387 

on  skin,  406 
modes  of  infection,  131,  485 
of  hip-joint,  861 
of   pericardium,   342 
of  tonsils,  410 
predisposing  causes,   486 
acute,  483 

bacteriologj',    486 
D'Espine'si  sign  in,  494 
diagnosis,  496 

from  faulty  metabolism,  300 
from  syphilis,  678 
Tuberculosis,      acute,      diagnosis,      from 
typhoid,  495 
sputum,   495' 

method  of  obtaining,  495 
tuberculin   reaction,   496 
etiology,  483 

pathological  anatomy,  489 
prognosis,  496 
symptoms,    493 
night  sweats,  498 
physical    signs,    493 
in  nurslings,  494 
resembling  intermittent  fever,  493 
temperature,  493 
treatment,  497 

heliotherapy  in,  498 
bovine,  483 

chronic  pulmonary,  479 
pathology,  479 
symptoms,  481 
treatment,  497 
miliary    ( see  Acute ) . 
Tubercvilous  adenitis,  714 
ankle-joint,    865 
broncho-pneumonia,  479 
coxitis,   862 
elbow-joint,    865 
hip-joint,   861 

infection,  through  milk,   122,   131,  483 
knee-joint,  864 


Tuberiiil.Mis   nodules,  780 
pneumonia,   477 
wrist- joint,  865 
Tumor  of  bladder,  387 
of  kidney,  379 
sacral,  62 

spindle-cell  sarcoma,  842 
spongy    (see  also  Angeioma),  57 
Tunica  vaginalis,   hydrocele  of,   363 
Turbinates,  hypertrophied,  causing  bron- 
chial asthma,  428 
Turpentine  stupes,  896 
Twitching,  in  chorea,  746 

in  meningitis,   782 
Tympanites    (see  also  Intestinal  Colic), 
273 
a  symptom  of  worms,  291 
complicating  typhoid,   654 
in  intussusception,  287 
Typhoid  fever,  646 
bacteriology,  646 
complications,    654 
course,    654 
diagnosis,   650 
eruption,  651 
etiology,    646 
foetal  and  infantile,  647 
internal  haemorrhage,  653 
intestinal    perforation,    653 
.  leucopaenia  in,  652 
pathologj',  646 
prognosis,  646 
symptoms,   648 
temperature,   649 
treatment,  654 
vaccine,  542 

Uffelmann's  test  for  lactic  acid  in  stom- 
ach  contents,   875 
Ulcer,  in  scrofula,  681 
in  syphilis,  681 
of  stomach,  234,  696 
of  tonsil,  405 
Ulcerations,  aphthous,  206 

due   to   intubation   tube,   543 
Ulcerative  proctitis,  295 

tonsillitis,  522 
Ulcero-membranous   tonsillitis,   405 

resembling  diphtheria,   520 
Umbilical  cord,  17 

haemorrhage   from,   42 

in  syphilis,  675 
hernia,   288 
polypus,  36 
Umbilicus,   bleeding  from,   35,   39 

in  Meckel's  diverticulum,  36 
Uncinariasis,  293 
Undescended  testicle,  365 
Unna's   soft  zinc   paste,   828 
Uraemia  in  post-scarlatinal  nephritis,  617 
Urea  in  diabetes  insipidus,  383 
Urethra  in  vaginitis,  368 
Urethral  calculi,  386 
Urethritis,  366 
I'ric  acid,  in  blood,  708 


60 


946 


INDEX. 


Urie  acid,  in  iirine,  880 
of  new-born,   878 
Uricacidsemia    (see   also  Lithaemia),   705 
Urine,  877 

albumin  in,  878 

ammoniacal,  132 
test  for,  881 

bloody,   382 

diazo-reaction   in,   883 
in  typhoid,  651,  653 

disinfection  of,   656,   894 

fermentation  test,  887 

first,  877 

in  atrophy,  875 

in  auto-intoxication,  283 

in  colicystitis,   385 

in  cystitis,  387 

in   derangement  of  liver,   348 

in  diabetes   insipidus,  383 

in  diabetes  mellitus,  385 

in  diphtheria,  228,  515,   879 

in  epilepsy,   764 

in  gastro-duodenitis,   228 

in  icterus  neonatorum,  878 

in  leviksemia,  880 

in  lithsemia,  708 

in  measles,  588 

in   nephritis,    372 

in  pneumonia,  467 

in   pj'elitis,    377 

in  scarlet  fever,  604,  606 

in   septic  diphtheria,   523, -526 

in  typhoid,   651,  653,  656 

in  tuberculosis,  493 

in  Winckel's  disease,  41 

incontinence   of,    in   multiple   neuritis, 
752 
in  ectopia  vesicae,  378 

indican,   test  for,   884 

method  of  collecting,  877 

of  breast-fed  babies,   877 

of  new-born  babies,  878 

sodium  chloride  in,  878 

specific   gravity,    886 

sugar  in,  383 
test  for,  885 

test  for  blood  in,  885 

test  for  diacetic  acid,  886 

test  for  pus,  886 

urobilinogen  reaction  in,  238 
Urino-pyknometer,  880 
Urticaria,    S30 
Useless    coughs.    422 
Uvula,  bifid,  215 

enlarged,     causing    bronchial    asthma, 
428 

inflamed,  in  spasmodic  laryngitis,  417 

in  scarlet  fever,   604 

Vaccination,    644 
Vaccines,  bacterial,  450 

autogenous,   451 

stock,   451 

in  erysipelas,  452,  600    . 

in    furunculosis,    451,    835 


Vaccines,  in  pertussis,  452 

in  pneumonia,  454 

in  rabies,  451 

in  sinus  thrombosis,   818 

in  streptococcus  infections,  452 

in  tonsillitis,   452 

in   typhoid,   452 

in  vulvo-vaginitis,   451 
Vaccinia,   645 

Vagina,    rectum   terminating   in,    64 
Vaginitis,    366 

catarrhal,  366 

following   scarlet   fever,    617 

gonorrhceal,    366 
Varicella,    633 

complicating    erysipelas,    635 

diagnosis,   633 

from   impetigo,   635 
from   variola,   634 

pathology,   633 
■  treatment,    636 
Variola,    638 

complications,   642 

desquamation,    640 

diagnosis,  differential,  641 

eruption,   639 

etiology,   638 

isolation,    642 

mode  of  infection,  639 

mortality,  638 

prognosis  and  course,  642 

symptoms,   639 

treatment,   642 
Varioloid,    641 
Vascular   nsevus,    836 
Vasomotor     disturbance     causing     asth- 
matic  attacks,  -  428 
Vegetable   milk,   Lahmann's,   178 
Vein,  transverse  nasal,  in  adenoids,  412 

umbilical,.  325 
Veins,     engorgement    of,     in     insolation, 
246 

of  abdomen,  in  ascites,  358 

of  scalp,   in  hydrocephalus,  775 
in   rachitis,   312 

splenic,   in  malarial  fever,  667 

varicose,   in  chlorosis,   696 
Velum    palatinum,   in   diphtheria,   512 
Venesection,  897 
Venous  murmurs,  332 
Vermiform   appendix,   location  of,   73 
Vernix  caseosa,  18 
Verruca,  838 

Vertebrae,   in   scoliosis,   857 
Vertigo,  a  symptom  of  worms,  290 
Vesical  calculi,  386 
Vicarious    menstruation,    368 
Vincent's  bacillus,   406 
Vitamines,   144 
Vocal   resonance,   424 
Voice,   husky,   in    papillomata,    846 
in  pleurisy  with   effusion,   438 

in  syphilis,   680 

nasal,  in  diphtheria,  511,  526 

with   hypertrophy   of   tonsils,   408 


INDEX. 


947 


Vomiting,  ^1 

chronic,   228 

cyclic,   235 

faecal,    in    intussusception,    281,    286 

in  dilat<ation  of  stomach,  231 

in  diphtheria,  514 

in   gastrointestinal   haemorrhage,   41 

in   Henoch's   purpura,   708 

in   influenza,   398 

in  measles,  585 

in  meningitis,  782,  786 

in    pachymeningitis,    794 

in  pertussis,  456 

in    premature    infants,    33 

in   pyloric  obstruction,  224 

in  rubella,  578 

in   scarlet  fever,   600,   604 

in  typhoid,  649 

significance  of,   71 
Vulvo- vaginitis,    366 

following  scarlet  fever,  622 
serum  treatment,  451 

Walking,  first  attempts  at,  2 

in  congenital   dislocation  of  hip,   863 

in  hereditary  ataxy,  767 
Wampole's  milk  food,  186 
Wandering    pneumonia,    464 

spleen,   352 
Warts    (see  also  Verruca),  838 

syphilitic,    682 
Wassermann  reaction   in   syphilis,   678 
Wasting  disease,   321 
Water-ices,   201 
Water   on   the   brain    (see   also    Chronic 

Hydrocephalus),   776 
Waxy  liver,   349 
Weaning,   107 
Weighing  to   determine   the   quantity  of 

milk  an  infant  has  taken,  109 
Weight,  at  birth,  109 

disturbance,  108 

effect  of  sugar  feeding  on,   136,   137 

gain   in,  of  an   infant  fed   on  Eskay's 
food.  111 


106 


Weight,    giiiii    in,    of   an    infant    fed    on 
modilird  (i)ilk,   112 
on  modirrs   milk,   109 
on       Walker  Gordon       modified 
milk,  112 
of  a  prematurely  born  infant,  33 
of  a  wet-nursed  infant^   111 
loss  of,  299 

during  first  week,  80 
Weight-scales,   Chatillon,   108 
Werlhof's     disease     (see     also    Purpura 

Haemorrhagica),  706 
Wet-nurse,  97 

dangers   of   syphilis,   210 
diet  of  a,   103 
how  to  examine,  97,  99 
selection  of,   97,   100 
•     tricks  of  a,  98 
with  goiter,  98 
Wet-nursing,  in  New  York, 

in  Prague,   105 
Wheal  in  urticaria,  830 
Whey,   873 
Whooping-cough     (see     also     Pertussis), 

455 
Widal's  reaction  in  typhoid  fever,  650 
Winckel's   disease,   40 
Woman's  milk    (see  Milk). 
Worms,   causing  convulsions,   739,   741 
pinworms,  292 
roundworms,   290 
tapeworm,   289 
threadworm,   292 
Wrist-joint  disease,  865 

in  rachitis,  314,  315 
Wry-neck    (see  also  Torticollis),  704 

Xanthin,   708 

X-ray    examination,    as    diagnostic    aid, 
15 

Yawning,  in  malarial  fever,  671 
Zoolak,   189 


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